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jbmd, Board Certified Physician
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Experience:  Board Certified physician in Internal Medicine - 30+ years experience
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For several years I have had shaking and tremor episodes,

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For several years I have had shaking and tremor episodes, didn't know what to do, so I would alsways go to the E.R. because I would begin panicking (I already have anxiety as it is.) The E.R. doctors always diagnosed panic attacks.
I recently had a terrible episode of tremors, shaking, breathing problems, writing, communicating that lasted for over a month, and saw a neurologist who is also a movement specialist. I was diagnosed after my MRI with Essential Tremors.
I can't tell if my tremors are from panic attacks or the essential tremor diagnosis. The Inderal I take doesn't work too well for the shaking, but when I took Clonazapam (which is recommended for essential tremors, like Ativan), it seemed to help the tremors somewhat. I get scared and go to the E.R. when these episodes occur because when they inject Ativan it works better and gives my brain "a chance to rest and reset itself". I know that sounds strange.
The psychiatrist can't say how long panic attacks last, the neurologists say the tremors can go on for a month, and I'd rather just go to the E.R. and get a shot (which I know isn't a cure and that's not what the E.R. is for.)
Any suggestions? I coincidentally had tremors and severe back pain last July, and the E.R. doctor gave me Ativan, Zofran, and a pain shot of Dilodad (I can't remember, but it wasn't morphine). Although I still had pain in my back for a month, the tremors disappeared pretty quickly, unlike with the Inderal I'm taking.
I have seen a Pain Management doctor before but they're not going to give me pain or anxiety shots when I'm not in pain to treat tremors.
I get these episodes about once or twice a year, and that's when I have visited the E.R. Now the neurologist said it's the tremor condition, but his medication is doing nothing. I still feel safer going to the E.R.
So how do you know if it's an extended, long panic attack or essential tremors? Thank you?
Hello from JA
You need to work with your doctor not the ER, for cost purposes alone, and because an ER doctor is not a specialist in this.

It sounds like panic, but could also be anxiety/panic and tremor. Both.

The way to sort this out in my view is to use the correct medicine for anxiety/panic, an SSRI medication such as zoloft.
This will take 4 weeks on it to see if it is having a positive effect, but at this point that would be the test...and you need to talk to your psychiatrist about this.

OK. If you have further questions or details, use reply to expert.

DrRussMD, Board Certified Physician
Category: Medical
Satisfied Customers: 64938
Experience: Internal Medicine--practice all of internal medicine, all ages, family, health, prevention, complementary medicine, etc.
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Customer: replied 4 years ago.

Hi again,

I already take 200 mg of Zoloft and have tried almost all of the SSRI meds for anxiety or if it was essential tremors, the SSRIs don't work for either the anxiety or essential tremors. My psychiatrist now wants me to add on Aplenzin ER 174 mg to the Zoloft (Wellbutrin with bromide), but I've taken Wellbutrin before and it doesn't work. Plus, I get severe dry mouth, and that's the top side effect of Wellbutrin.

I am trying to get-off Clonazapam because I'm beginning to build up a tolerance, and I want to save it for when I have another bad shaking episode.

I could feel the last shaking episode coming on in November and December 2012, and it was a steady decline. All of my appendages, including my head, would shake in a pattern. Also, when I was in a resting period or sleeping, I would get strange bolts or twitches of energy in different parts of my body, and it would wake me up.

Then in January 2013, the shaking appendages deteriorated so rapidly I couldn't control them anymore. I didn't go to the E.R. It took almost three weeks to get two different appointments with two different neurologists. I had difficulty communicating, driving, writing, and the shaking was so intense that I couldn't hold a glass of water without people staring.

At the end of January, the second neurologist, who is also a motor specialist, analyzed both of my MRIs (spine and head) and told me that I didn't not have Multiple Sclerosis, Parkinson's, Hunington's, etc. He diagnosed the essential tremors, and prescribed the clonazapam and 180 mg of Inderal per day as needed.

I noticed a big difference initially with the clonazapam, and now that it's the end of March, a person would not notice that I still slightly shake in my appendages. I am just worried that if I get another BIG episode like the entire month of January, do I go to the E.R. to get an Ativan shot since it's stronger than Inderal and anti-anxiety pills? Plus, the Inderal doesn't work immediately. I never want to go through another shaking episode like that again. I feel so lost.

I have appointments next month to consult again with the psychiatrist and the neurologist's physician assistant. They both are going to look at me and think I appear completely normal.

I have been researching the essential tremors online, especially the official website of essential tremors. There really seems to be no medication specifically developed for the tremors, but they do mention Inderal, Primitone, and Clonazapam as meds to help.

I am a school teacher and cannot miss a month of teaching with another bad episode of a month of shaking severely. Any suggestions? Please?

Customer: replied 4 years ago.
Relist: Answer quality.
need neurology
Your question has been in neurology since it came here.
No one has taken it.

What stands out on your story is not much follow up or treatment other than the ER?

List all medications you have had
Anything else?
Customer: replied 4 years ago.

I've been complaining about shaking for five years and saw one neurologist who performed EEGs and MRIs (normal). My shaking was in the normal range so she didn't say much, but people at work notice my tremors. When the first neurologist saw me severely shaking in January 2013, she immediately said MS. I saw a second neurologist who said not MS or Parkinson's; essential tremor attack after analyzing my MRIs.

In the past, the E.R. said that they were panic attacks so I've been seeing a psychiatrist and tried all the SSRIs and benzos for anxiety.

List only the meds for the essential tremors diagnosed in January?

-Inderal (60 mg up to 3 times per day; right now I might take one or two since I'm no longer having severe tremors; my blood pressure and pulse rate is normal so I'm afraid to take more Inderal )

-Lisinopril 30 mg

-Clonazapam up to 6mg per day, (but now I'm only taking 1 mg or nothing per day so that I don't build up the tolerance in case of another severe attack)

-Zoloft 200 mg

-Wellbutrin XR with bromide

-the first neurologist suggested Trazodone which I had already been taking for sleeping, and it obviously did not stop the tremors from occurring for years. It stopped working for sleeping so I'm not taking it.

I still have slight tremors but not noticeable at all. I want to prevent another big episode like the one that lasted throughout January.

I also take:

Armour Thyroid (Hashimoto syndrome) 120 mg

Byetta 15 mcg (pre-diabetic; diabetes 2 runs in my family)

Ambien occasionally 10 mg

That's why I asked the question of getting a shot of Ativan from the E.R. (it seems to "reset" my brain faster than the pills) and the shaking is less severe. Again, I didn't go to the E.R. in January and suffered through that really bad tremor attack with taking Clonazapam and Inderal. I can't miss that much work again.

Is that it for me? No way to prevent a future, severe tremor attack or whatever it was?

Thank you and I know my question is complicated.

I shot of ativan would not be a way to prevent tremors in the future.
It is acute management.
IT is short acting in fact.

If you need to do it, your tremors are increasing, and it works, then you can...your doctor might also arrange this with you.

Increasing the inderal dose is another option in an attempt to prevent an increase in tremors.

Magnesium is the most common nutrient needed in this situation.

Gabapentin might replace the inderal if the inderal is not working well enough.
This is a completely different medicine, not the same side effects [lethargy] and works on the brain directly.

OK. If you have further questions or details, use reply to expert.

Customer: replied 4 years ago.

I am on disability right now and financially poor, but you did a great job in listening to all of my details. I wish there was some way to prevent another big shaking episode. How much magnesium would you recommend?

As long as your kidneys are OK and you have doctor clearance...500 mg a day
Preferably magnesium taurate.

OK. If you have further questions or details, use reply to expert.

Customer: replied 4 years ago.

Can I still give you a smiley face, bonus, but ask for a neurologist to review?

It is still in neurology
And after you do that let me know and I will alert them as well.
DrRussMD, Board Certified Physician
Category: Medical
Satisfied Customers: 64938
Experience: Internal Medicine--practice all of internal medicine, all ages, family, health, prevention, complementary medicine, etc.
DrRussMD and 6 other Medical Specialists are ready to help you
Your follow up posts are already in neurology.

I will post one answer and then opt out as I'm not a neurologist: some of the medications you are on can cause tremor--perhaps you knew that. Wellbutrin and Zoloft are two of them. I will send a message to a neurologist online now.

If the tremors started after you began them, you might consider weaning off (the Zoloft very slowly!) with your doctor's oversight and using a non-medication therapy like bio- or neuro-feedback (with the possible addition of acupuncture), if your insurance will pay for those modalities and they're available in your area.

Customer: replied 4 years ago.

Yes, please send my question to a neurologist becuase I have consulted with two already in person, and on one of the web sites Zoloft is recommended.

This is all so confusing. I am having trouble accepting middle age and I don't want another severe tremor attack that lasts for over a month, so I'll definiely keep up with the Inderal. It's just that I take Lisinopril 30mg two, and taking two or three Inderals a day has put my blood pressure and pulse rate at a perfect level. I am afraid to increase the Inderal because I don't want light headnesses or low blood presure as a result.

I notified an online neurologist as soon as I posted to you but I see no one has answered. I'll opt out again and try to direct it again. Wish I could do more!
jbmd, Board Certified Physician
Category: Medical
Satisfied Customers: 615
Experience: Board Certified physician in Internal Medicine - 30+ years experience
jbmd and 6 other Medical Specialists are ready to help you
Hi--I didn't want you to rate or pay me last time. I messaged a different neurologist but don't see an answer so I will give you some advice from me. Unfortunately I can't examine or treat you or replace a local doctor.
My impression is that your shaking is more likely from anxiety than from an essential tremor as it's coming and going. The drugs you're on can both treat and cause tremor. I'd recommend finding a sympathetic psychiatrist or even better a neuropsychiatrist--one boarded in both fields.
My recommendation would be to try neurofeedback IF you can afford it or you insurance would pay (it is often tremendously helpful, doesn't involve drugs, takes a reading of your brain like an ECG does of your heart so NO electricity comes in, and trains you to control your moods and maybe by that way, your shaking. It has a longer-lasting effect than the drugs without side effects and can be touched up with extra sessions as needed. Biofeedback might help you too if neurofeedback is not available where your live. It's good for ADHD, bipolar, etc.
Reply to me if you wish. I'll be glad to respond but don't rate again! I don't want you to spend any more money. Here is a NYTimes article on it:
I've had it make remarkable changes in people I know and no, I don't treat it myself but refer to others who do, so I'm not a commerce-driven enthusiast.
Customer: replied 4 years ago.

Thank you for your advice! I've been on Zoloft a long time and began having minor shaking in my hands since my 30s (I'm 45). So I stopped drinking caffeinated drinks (didn't help the shaking), exercised a lot, got plenty of rest.

I've tried many SSRIs but I don't feel any results regarding anxiety, depression, and tremors. The only reason why I went back to Zoloft was because my psychiatrist said you can alter the dosage around unlike other SSRIs.

The psychiatrist just started me on Wellbutrin (Aplenzan ER 174) because it has bromide in it, which is supposed to help nausea (which I also have). Then I looked at the side effects of Wellbutrin, and the top one was dry mouth. I have terrible dry mouth, do you think it's from the Wellbutrin? I know that muscle relaxers, lomotil cause dry mouth. Ugh! So I think I'll stop taking it.

Also, when the severe tremor that lasted throughout January (I've never had all of body parts shake before for a month), I took 6mg of Clonazepam (my body is like a horse, I get no relief from low mg of any drug).

Should I just take 2 mg a day for a week to get off of it? I can also split the 2mg of pill if needed. Like I said before, I want its effects to work when I really need it.

Neurofeedback sounds great! I do get anxiety a lot, but all I have is Blue Cross HMO. They keep raising their rates for my school district, and I think I'll need to switch to Kaiser next year.

Again, thank you for all of the advice! I'm going to read the article you recommended now.

I can't really give advice on how you should manipulate your meds or what you should get off of. It sounds as if your medical history is quite complex and symptoms and medications are all tangled up in your history: what came first--symptom or drug?
You need someone to really sit and listen to you and work out what to try changing if anything. It can be hard to wean off any of these drugs, especially going alone without advice.
I've had lots of patients have shaking or hand and jaw clenching on SSRI medications but that doesn't mean that YOURS is due to that.
You might have an easier time getting to a specialist with Kaiser--that I don't know.
Meanwhile, make sure you do meditation and yoga and exercise aerobically if you are safely able to and PUSH to get the care you need!
Remember that stress is a great mimicker of other problems: it can cause all the symptoms of tremor and even seizure and things like asthma. Evaluation by good doctors with patience and the knowledge of what tests to do can sort things out for you.