Symptomatic Management of Multiple Sclerosis–Associated
Tremor Among Participants in the NARCOMS Registry

William Meador, MD; Amber R. Salter, MPH; John R. Rinker II, MD

Published in the International Journal of Multiple Sclerosis Care (IJMSC) in May/June 2016,
ijmsc.org/doi/full/10.7224/1537-2073.2015-008?=&code=cmsc-site

      As many people who live with Multiple Sclerosis (MS) are well aware, effective and well-tolerated medical options for the management of many symptoms in multiple sclerosis can be hard to find. One symptom that is particularly common and difficult to manage in MS is tremor. Published research reports the frequency of tremor in MS patients between 25% and 58% with up to 15% of MS patients living with moderate or severe tremor. These same studies have shown that tremor is related to a higher rate of neurologic-related disability and reduced quality of life. For such a common and potentially disabling symptom, tremor is very rarely studied in multiple sclerosis.   

      A research team at the University of Alabama at Birmingham (UAB) wanted to investigate how patients living with multiple sclerosis–related tremor attempted to manage this symptom with the help of their physician. NARCOMS participants who reported tremor in their annual surveys were sent additional surveys with questions focused on their tremor, the impact of the tremor on their daily function and quality of life, and the treatment(s) they utilized to help with this symptom.

      More than 500 NARCOMS participants returned completed surveys.  Just under half of those who responded to the survey and reported tremor (238; 46.9%) reported taking medication to manage their tremor symptoms.

      Symptomatic drug use was more likely in participants reporting moderate (53.9%) or severe (51.3%) tremor than in those with mild (36.6%) or totally disabling (35.0%) tremor. The researchers believe that this reflects several things:

  • MS tremor remains undertreated and under-recognized by treating physicians
  • MS tremor is difficult to treat
  • The medications used to treat MS tremor carry side effects that often outweigh the modest benefit.    

      Respondents who reported the use of symptomatic medications for their tremor were more likely to not be working and were more likely to have more severe tremors.  Interestingly, patients who had moderate or severe tremors were more likely to use a medication to control their tremor than those with mild or disabling tremors (Figure 1).    

      This may reflect the fact that mild tremors are not disruptive enough to warrant medication and once a tremor is disabling, the doses of medications required to help the tremor may produce intolerable side effects. We also asked respondents which medications they used to try to treat their tremor.  Nearly two-thirds of respondents reported using only one medication to control their tremor while the others used two or more medications.

   FIGURE 1.

  

     

      Of the types of medications used, respondents reported overwhelmingly that they used either anticonvulsant medications—medications originally designed for seizures—and/or benzodiazepines, for example lorazepam, diazepam, clonazepam (Figure 2).  These classes of medications appear to be the most frequently prescribed in MS patients with tremor. This may reflect a bias of the treating physician to use medications with which she or he is familiar, or it may reflect an attempt to use medications which may help both tremor and other symptoms, such as pain or spasms.  

 

FIGURE 2.

 

      These findings confirmed that when tremor is present in multiple sclerosis, it commonly contributes to disability and reduced quality of life. We also found that most patients do not take medications that help their tremor. These results, combined with other research, such as Koch, et al, support the notion that MS tremor is difficult to treat and warrants further study, as it significantly contributes to disability.