How do you approach the management of Holmes tremor?

Holmes tremor (HT) is characterized by a low frequency (<4.5Hz), large amplitude and irregular rest, action and postural tremor, often affecting the proximal muscles. The exact pathophysiology of HT remains unknown, however, lesions involve the cerebello-thalamo-cortical or dentato-rubro-olivary pathways. Superimposed dysfunction of the nigrostriatal pathways may account for the rest tremor component. Work up for HT includes brain imaging and the term HT is preferred given that "rubral tremor" is anatomically misleading given that lesions outside of the midbrain can present with HT phenomenology.

Pharmacotherapy is often challenging, but response has been reported with levodopa, trihexyphenidyl, clonazepam, bromocriptine, levetiracetam, and...