Symptomatic Treatment of MS - European Multiple Sclerosis Platform

Antiepileptics:
Primidone may be effective in essential tremor but sedative side effects limit its use. Gabapentin will
ameliorate essential and orthostatic tremor and carbamazepine [Sechi 1989] as well as topiramate [Sechi
2003] may positively influence cerebellar tremor.
Other drugs:
Clonazepam (3-6 mg/d) may be of some benefit in cerebellar tremor, too [Trelles 1984]. The effect of
Oxitriptan (5-hydroxytryptophane) on ataxia of the trunk and legs usually occurs only after treatment
with 3x300 mg/d over about 6 weeks [Trouillas 1988]. Up to now, ondansetron, a 5-hydroxytryptophan-
(HT-3)-antagonist, showed conflicting results. Using 8 mg of oral Ondansetron no significant reduction
of cerebellar symptoms could be demonstrated [Gbadamosi 2001; Bier 2003], whereas intravenous
ondansetron (8 mg/d) caused a clear short lasting amelioration of writing ataxia and of the patients´
subjective impression [Rice 1997]. Isoniazid has been used in patients with cerebellar tremor with
conflicting results [Koller 1984; Hallett 1985]. Adverse effects may limit treatment. Physostigmine has no
significant effect on cerebellar tremor [Duquette 1985; Wessel 1997].
SURGICAL TREATMENT
With stereotactic operations, e.g. VIM thalamotomy and VIM (deep brain-) stimulation, reduction of
tremor could be demonstrated though [Bittar 2005] VIM thalamotomy is not as effective in MS patients
as in those with Parkinson´s disease. Chronic VIM stimulation will produce better results but stimulation
parameters probably have to be optimized repeatedly. In some smaller studies and case series amelioration
of tremor could be achieved in 87.7 % and of activities of daily life in 76 % of operated patients
[Wishart 2003]. Simultaneously the level of disability and SF-36 subscales remained largely unchanged
[Hooper 2002; Berk 2002]. Fortunately peri- and postoperative complications are rare. Best treatment
results may be achieved in patients with stable tremor, e.g. marked axial and proximal arm tremor, and
trunk ataxia [Alusi 2001]. If stereotactic treatment is considered, the patients’ disease course should be
stabilized by effective immunotherapy for at least one year.
RECOMMENDATIONS
� Regular physiotherapy and occupational therapy, cooling.
� In patients with predominant tremor: additional drug treatment (monotherapy) with a beta blocker
(rapid assessment of efficacy) and, if not successful, monotherapy with carbamazepine, primidone
or clonazepam. If escalation is necessary combination therapy with a beta blocker and an
antiepileptic drug. Efficacy of these drugs is often limited by their extensive adverse effects.
� If tremor is unresponsive to combination therapy: oxitriptan
� Only in patients with considerable tremor unresponsive to drug treatment or with severe side effects
electrical stimulation of the thalamus should be considered.
25 EMSP, Symptomatic Treatment of Multiple Sclerosis, December 2006 - revised in April 2008