chronic

Essential tremor

Treatment options, dosing, cautions and Egyptian brands from the shipped Dawaa Reference card.

Evidence status

Checked against the sources named below

Sources2 sources

Primidone SERB 250 mg Tablets SmPC section 4.2, Essential tremor (eMC product 2940): "Initially a dose of 50 mg daily should be introduced in a single intake late afternoon, using, when available, the 50 mg tablet. The daily dose (given in 2 divided doses) should be increased gradually over a 2 to 3-week period until remission of symptoms or the highest dose tolerated up to a maximum of 750 mg daily." · Egyptian National Drug Formulary - Cardiovascular 2024 (propranolol monograph)

Verified against2 documents

Egyptian National Drug Formulary - Cardiovascular 2024 (propranolol monograph)
Primidone SERB 250 mg Tablets SmPC section 4.2, Essential tremor (eMC product 2940): "Initially a dose of 50 mg daily should be introduced in a single intake late afternoon, using, when available, the 50 mg tablet. The daily dose (given in 2 divided doses) should be increased gradually over a 2 to 3-week period until remission of symptoms or the highest dose tolerated up to a maximum of 750 mg daily."

Verified date2026-08

Presentation reference

Is it this?

Reference only, to read alongside your own examination.

Symptoms — what the patient reports (5)

The tremor usually affects both hands and arms equally, though one-sided cases occur [tremor]
Tremor frequency typically falls between 6 and 12 Hz [tremor]
The shaking gets worse near the end of a targeted task like lifting a glass or touching finger to nose [tremor]
A small amount of alcohol eases the tremor in 60% to 70% of patients, and caffeine does not typically worsen it [tremor]
A tremor present for more than 3 years and a family history of the same tremor both support the diagnosis [tremor]

Signs — what you find (5)

On exam the tremor appears both when the arms are held out against gravity and during a targeted task [tremor]
Leg tremor is uncommon; a resting leg tremor instead suggests a Parkinsonian cause [tremor]
A head tremor may nod up-and-down in about 25% or shake side-to-side in about 75%, usually with hand or voice tremor [tremor]
Head tremor without any hand involvement raises concern for cervical dystonia instead [tremor]
Some patients also show mild cerebellar signs such as an unsteady tandem gait

Tests (3)

Diagnosis rests on bilateral hand and forearm action tremor with no other neurologic abnormality
No blood test or scan confirms essential tremor itself; testing is used only to rule out other causes
A specialized dopamine-transporter brain scan can reliably separate Parkinsonian syndromes from essential tremor

If not this — what else fits (6)

A high-frequency tremor of 10 to 12 Hz with an identifiable cause like medication or hyperthyroidism points to physiologic tremor
A resting, asymmetric tremor at 4 to 6 Hz without head involvement points to Parkinson disease
A fast 14 to 20 Hz tremor felt in the trunk and legs on standing, easing with walking, indicates orthostatic tremor
A slow 3 to 4 Hz tremor accompanied by ataxia and dysmetria points to a cerebellar cause
A tremor appearing only while writing, absent in other coordinated tasks, suggests task-specific writer's tremor
Abrupt onset, spontaneous resolution, and disappearance with distraction point toward a psychogenic tremor

SourceStatPearls "Essential Tremor" - disease-level clinical article

Presentation findings are traced to the source above.

PROPRANOLOL

1st line

Strength40 mg

Formoral.solid

Adult dose and duration

40 mg twice daily initially, titrate up to 80-160 mg daily in divided doses (max 320 mg daily) - long-term

Paediatric dose

Essential tremor is rare in pediatric populations; specialist referral required

Dose source

Egyptian National Drug Formulary - Cardiovascular 2024 (propranolol monograph)

Why

Non-selective beta-blocker used first-line for essential tremor; it dampens the peripheral component of the tremor, reducing its amplitude.

Cautions

CONTRAINDICATED in bronchial asthma, severe COPD, second/third-degree heart block, and sick sinus syndrome.
May mask symptoms of hypoglycemia in diabetic patients.
Avoid abrupt withdrawal (risk of rebound tachycardia and hypertension).

Egyptian brands

Egyptian brand	Manufacturer	Indicative price
INDOLOL 40 MG 50 TAB	KAHIRA	13.50 EGP (0.27/unit)
PROLOL 40 MG 50 TABS.	EIPICO	70.00 EGP (1.40/unit)
INDERAL 40 MG 50 TABS	ASTRA ZENECA	100.00 EGP (2.00/unit)

PRIMIDONE

2nd line

Strength50 mg

Formoral.solid

Adult dose and duration

50 mg once daily in the late afternoon initially, then increase gradually in two divided doses over a 2 to 3-week period until the tremor settles or the highest tolerated dose is reached, to a maximum of 750 mg daily - long-term

Paediatric dose

Specialist neurology use only in children

Dose source

Why

Primidone is not registered or marketed in Egyptian commercial pharmacies; propranolol is the primary Egyptian first-line agent.

Cautions

Unregistered and unavailable in Egyptian commercial pharmacies.
First-dose acute reaction (severe dizziness, ataxia, nausea) common if started at standard dose; start very low.
Metabolized in part to phenobarbital; causes sedation, lethargy, and ataxia.
Abrupt withdrawal can precipitate seizures.

Egyptian brands

No Egyptian brand matched — prescribe by generic name.

Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy.