Objective: Orthostatic tremor is notoriously difficult to treat. To date, there has only been one case report of marked improvement of symptoms using perampanel. We present a case that redemonstrates similar findings using perampanel for the treatment of this condition.

Background: Orthostatic tremor continues to remain a therapeutic conundrum. Due to the rare nature of this disorder there have not been any well designed randomized controlled trials. Anecdotal evidence supports the use of various medication classes such as benzodiazepines, beta blockers and antiepileptic agents. However, results remain modest at best.

Method: A 62-year-old female with a 13 year history of primary orthostatic tremor, confirmed on EMG in the arms (while bracing against a desk) and legs (while standing) and refractory to clonazepam up to 20mg/day, was treated with perampanel 1mg/day with an additional 1mg/day as needed.

Results: She reported 90% subjective symptomatic improvement after using it for 4 months. She had no side effects. However, she did continue to have high frequency tremor on EMG in the quadriceps on standing, while reporting no tremor symptoms.

Conclusion: This case highlights the potential for use of a novel AMPA (α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) receptor antagonist for the treatment of primary orthostatic tremor. Perampanel is primarily used as an antiepileptic medication, at higher doses than we have used in this patient. It acts by blocking glutamate activity at the post-synaptic AMPA receptors. Side effects include significant psychiatric symptoms, for which every patient should be screened regularly. There has been one prior case report citing its use for orthostatic tremor with complete resolution of symptoms. Akin to the previously published report, the patient continued to have persistent tremor on EMG, pointing only towards a symptomatic benefit rather than one targeting the underlying etiology, which remains poorly understood. We encourage further studies to highlight its efficacy for orthostatic tremor.

References: [1] Ruiz-Julián M, Orozco JL, Gironell A. Complete Resolution of Symptoms of Primary Orthostatic Tremor with Perampanel. Tremor Other Hyperkinet Mov (N Y). 2018;8:552. Published 2018 Apr 17. doi:10.7916/D8QZ3SZD [2] Benito-León, J., & Domingo-Santos, Á. (2016). Orthostatic Tremor: An Update on a Rare Entity. Tremor and other hyperkinetic movements (New York, N.Y.), 6, 411. doi:10.7916/D81N81BT

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MDS Abstracts - https://www.mdsabstracts.org/abstract/successful-treatment-of-orthostatic-tremor-using-perampanel/