American Board of Internal Medicine (ABIM) Certification Practice Exam

Which medications are first-line treatments for essential tremor?

1. Carbamazepine and valproate

2. Propranolol and primidone

3. Gabapentin and clonazepam

4. Levetiracetam and tiagabine

The correct answer is: Propranolol and primidone

Propranolol and primidone are established as first-line treatments for essential tremor. Propranolol, a non-selective beta-blocker, has demonstrated efficacy in reducing the amplitude of tremors, likely due to its ability to modulate sympathetic nervous system activity. It is particularly beneficial for patients whose tremors worsen with anxiety or stress. This medication can be effective even at relatively low doses and is often the first medication tried. Primidone, an anticonvulsant medication, is also effective in treating essential tremor. It works through a different mechanism compared to propranolol, impacting the central nervous system. Primidone tends to be effective for patients who may not respond to or tolerate propranolol. Its benefits may also extend beyond tremor control, as it can address associated symptoms such as increased anxiety. Overall, the combination of propranolol and primidone provides a robust therapeutic strategy for managing essential tremor, emphasizing a dual action by targeting both peripheral and central mechanisms of tremor generation. The other options involve medications that are not considered first-line for essential tremor, as they either lack sufficient evidence of efficacy or are primarily indicated for different conditions.