Primidone and propranolol are the cornerstones of maintenance medical therapy for essential tremors. These medications provide good benefit, reducing tremor amplitude in approximately 50-70% of patient. Adverse effects are more prominent early in treatment with primidone but are more prominent later in treatment with propranolol. If she not achieve an adequate response with primidone and propranolol, try topiramate. Clozapine, an atypical neuroleptic, has been shown to be effective in essential tremor and poor response to propranolol or primidone. Some patients with disabling, medically refractory upper extremity tremor, surgery is considered. Stereotactic thalamotomy and thalamic ventralis intermedius nucleus deep brain stimulation are the procedures of choice. Both procedures offer high rates of tremor reduction in the contralateral arm. Information suggests that they are also useful in reducing head and voice tremor.[ thalamic stimulation might be a useful procedure on the opposite side in patients who have already had a unilateral thalamotomy, in an effort to avoid the potentially serious complications of bilateral thalamotomy.[48] Thalamic stimulation now is considered the procedure of choice.