To report a case of orthostatic tremor treated successfully with perampanel.

Primary orthostatic tremor (OT) is a rare movement disorder characterized by tremor limited to the legs and trunk which occurs only when standing still and disappears with sitting or walking. Medications currently used for treatment of OT including clonazepam and gabapentin have limited effectiveness. Perampanel is a selective AMPA glutamate antagonist used for treatment of focal and generalised epilepsies. Worldwide, only two case reports have previously described successful treatment of OT with perampanel.

Case report

This case report describes a 60-year-old man presenting with classical OT, i.e. with severe, symmetrical tremor in both legs which occurred only when standing, but not when walking or seated. The tremor was so severe that he could no longer stand in a queue when shopping. There were no other neurological deficits present, including no weakness, rigidity, bradykinesia, or autonomic features. He had no family history of tremors. He had previously been treated with gabapentin 400mg three times per day with only mild improvement in symptoms.

We trialled commencing perampanel 2mg per day, followed by gradual withdrawal of gabapentin. After 6 months of treatment, the patient’s tremor had almost completely resolved. He had greatly improved quality of life, with no adverse effects from the drug.

Perampanel seems a promising new treatment for historically difficult to manage primary orthostatic tremor.