s disease (HD) is a fatal neurodegenerative disorder, which usually manifests in middle age with motor, psychiatric and/or cognitive disturbances. In his recent review, Francis Walker stated that medical treatment of HD has made little progress in the past 20 years. 1 Despite a large number of reports on pharmacological interventions in HD, no treatment recommendation could be made in a recent evaluation of 20 randomized controlled clinical trials. 2 While symptomatic treatment of HD has been reviewed, 3 a systematic evaluation of current prescription practices is missing. We have analyzed the use of symptomatic treatment for HD based on more than 7,000 entries in the European HD REGISTRY between 2004 and 2007. The REGISTRY collects data from centres across Europe with particular expertise in HD. As many as 1,796 of 2,128 registered HD patients (84%) received symptomatic treatment. About 1,058 patients (50%) were treated for depression and 596 (28%) received antichorea medication. Among the other common indications, 268 patients (13%) were treated for irritability and aggression, 188 (9%) for sleep disturbance, and 152 (7%) for psychosis. Fewer than 2% of patients received medication for rigidity (35), obsessive-compulsive behaviours (24), apathy (12), or mania (4). The most commonly prescribed drugs were neuroleptics and antidepressants. About 321 HD patients (15%) received citalopram, 283 (13%) tiapride, 249 (12%) olanzapine, 202 (9%) paroxetine, 181 (8%) tetrabenazine, 180 (8%) risperidone, 165 (8%) sertraline, 137 (6%) haloperidol, and 122 (6%) sulpiride. The choice of drug depended strongly on cultural influences. Thus, at least a quarter of the patients on neuroleptics received haloperidol in Germany (24%) and Italy (32%), but only 12% in the UK and 14% in Spain. In the UK, olanzapine was the neuroleptic of choice (55%), while this drug was rarely prescribed in Germany (5%). Tiapride was the most common HD medication in Germany (38%), but this drug was unavailable or not used in other European countries. Citalopram was the single most commonly prescribed antidepressant in the UK (41%). Interestingly, citalopram was used less often in Germany (18%) and not at all in Spain (0%). In Italy, paroxetine was the most commonly prescribed antidepressant (47%). Our findings suggest that in HD, and probably other orphan diseases, patients need to be aware of the lack of evidencebased criteria for medication choices and might want to look beyond the border of their country for additional symptomatic treatment options.