Treatment Options and Management

Finding the right treatment for Primary Orthostatic Tremor (POT) can be a process of trial and error. Because the condition is rare, there is no single “cure-all” medication. Instead, the goal of treatment is to manage symptoms and increase the amount of time you can stand comfortably ^[1][2].

Important Safety Rule: Never start, stop, or change the dose of these medications without direct instruction from your prescriber.

Medication Options

Most doctors begin treatment with oral medications. While these can be helpful, it is important to have realistic expectations: benefits are often only partial, and they may decrease over time ^[3][4].

• Gabapentin: This is often considered a first choice because it has some of the most robust evidence among POT treatments ^[1]. It works by calming the overactive nerve signals in the brain and legs.
  • What to watch for: It can cause sedation, worsening dizziness, and swelling in the legs. Because it is cleared by the kidneys, your doctor will need to check your renal function before and during treatment ^[5].
• Clonazepam: This medication (a benzodiazepine) has traditionally been used for POT and is reported to help about 56% of patients in some specialist cohorts ^[3].
  • What to watch for: The benefit of clonazepam often “wanes” or wears off as the body builds a tolerance to the drug ^[6]. It also carries risks of physical dependence, increased fall risk, and significant drowsiness ^[4]. Do not stop taking it suddenly due to withdrawal risks, and avoid combining it with alcohol or opioids. The drowsiness can impair driving.
• Perampanel: This is an epilepsy medication that has shown significant short-term results in some patients, even at low doses, but its use for POT is off-label ^[7].
  • What to watch for: It is often difficult to tolerate. In one study, nearly 40% of patients had to stop taking it due to side effects like irritability, dizziness, or a “rebound” of symptoms if they missed a dose ^[7][8]. Patients should be monitored closely for serious behavioral or mood changes.

Advanced Options: Surgery and Stimulation

If medications fail to provide enough relief to perform daily activities, you and your doctor may discuss surgical interventions. These are typically reserved for medication-refractory cases, meaning the tremor persists despite trying several different drugs ^[2].

Deep Brain Stimulation (DBS)

DBS involves placing thin wires into specific areas of the brain—most commonly the ventral intermediate nucleus (Vim) or the zona incerta—and connecting them to a battery pack in the chest ^[2][9].

• The Goal: To increase “unsupported standing time.” In some small studies, patients went from being able to stand for 30 seconds to standing for several minutes after surgery ^[2][10].
• The Reality: DBS relies on small case series rather than large trials. It carries the risks of major brain surgery, including bleeding, infection, and stimulation-related side effects like ataxia (clumsiness, balance issues, or slurred speech) ^[11][12]. It requires multidisciplinary specialist assessment and ongoing programming appointments.

Spinal Cord Stimulation (SCS)

SCS uses a device similar to a pacemaker to send electrical signals to the spinal cord. It is currently considered investigational, meaning there is not yet enough evidence to call it a standard treatment ^[2][13].

• Current Research: Very small studies have shown that it may help some patients stand longer, but it often causes a “paresthesia” (a tingling or buzzing sensation) in the legs that some find distracting ^[14][15]. It should generally be considered only in a research setting or at specialized centers ^[16].

Summary of Common Treatments

Regardless of the treatment you choose, the most successful approach often combines medication with lifestyle adaptations, such as using high stools or rolling walkers, to maintain your independence ^[17].