(FDA approved in bold)

• Migraine prophylaxis
  
• Essential tremor
  
• Hypertension
  
• Angina pectoris due to coronary atherosclerosis
  
• Cardiac arrhythmias (including supraventricular arrhythmias, ventricular tachycardia, digitalis intoxication)
  
• Myocardial infarction
  
• Hypertrophic subaortic stenosis
  
• Pheochromocytoma
  
• Akathisia (antipsychotic induced)
  
• Parkinsonian tremor
  
• Congestive heart failure
  
• Tetralogy of Fallot
  
• Hyperthyroidism (adjunctive)
  
• Generalized anxiety disorder
  
• Post-traumatic stress disorder
  
• Prevention of variceal bleeding

• Migraine: Proposed mechanisms include inhibition of adrenergic pathway, interaction with serotonin system and receptors, inhibition of nitric oxide production, and normalization of contingent negative variation. Prevention of cortical spreading depression may be the mechanism of action for all migraine preventives
  
• Tremor: effectiveness is likely due to peripheral beta-2 receptor antagonism

• Migraines – within 2 weeks, but can take up to 3 months on a stable dose to see full effect
  
• Tremor – within days

• Migraine – goal is a 50% or greater decrease in migraine frequency or severity. Consider tapering or stopping if headaches remit for more than 6 months or if considering pregnancy
  
• Tremor – reduction in the severity of tremor, allowing greater functioning with daily activities and clearer speech

• Increase to highest tolerated dose
  
• Migraine: Address other issues, such as medication overuse, other coexisting medical disorders, such as anxiety, and consider changing to another drug or adding a second drug
  
• Tremor: Coadministration with primidone up to 250 mg/day can augment response. Second-line medications include benzodiazepines, such as clonazepam, gabapentin, topiramate, methazolamide, nadolol, and botulinum toxin (useful for voice and hand tremor.) For truly refractory patients, thalamotomy or deep brain stimulation of the ventral intermediate nucleus of the thalamus are options
  
• Alternatives for tremor include hand weights and eliminating caffeine. Low doses of alcohol reduce tremor, but is not generally recommended

• Migraine: For some patients, low-dose polytherapy with 2 or more drugs may be better tolerated and more effective than high-dose monotherapy. May use in combination with AEDs, antidepressants, natural products, and non-pharmacologic treatments, such as biofeedback, to improve headache control
  
• Tremor: Can use in combination with primidone or second-line medications

• None required