Essential Tremor

What essential tremor looks like

Essential tremor is an action tremor: it appears when muscles are working.

• Postural tremor: shaking when holding the hands out in front
• Kinetic tremor: shaking during movements, such as writing, pouring, buttoning or bringing a cup or spoon to the mouth
• usually affects both hands and arms, often one side more than the other
• head tremor: a nodding ("yes-yes") or shaking ("no-no") movement, more common in women
• voice tremor: a shaky, quavering voice
• less often, the jaw, tongue, legs or trunk

The tremor typically disappears at rest and during sleep. It worsens with stress, fatigue, caffeine, hunger and temperature extremes. Many people notice that a small amount of alcohol temporarily reduces it, which is a characteristic clue, though alcohol is not a safe treatment.

Essential tremor vs Parkinson's disease

Some people have features of both, and a neurologist can help tell them apart. See Parkinson's disease.

Causes and risk factors

• Genetics: about half of people have a family history. Children of a parent with essential tremor have a 50 in 100 chance of inheriting the tendency, though the genes involved are not fully identified.
• Age: it can begin at any age but becomes more common over 40 and especially over 65.
• Brain circuits: changes in the cerebellum and its connections are thought to cause it.

Other causes of tremor to rule out

• Enhanced physiological tremor: a fine tremor from caffeine, anxiety, fatigue, low blood sugar or stimulants
• Hyperthyroidism
• Medicines: asthma inhalers, lithium, valproate, some antidepressants, steroids, and others. See drug-induced movement disorders
• Alcohol or sedative withdrawal
• Dystonia: a jerky, irregular tremor with abnormal postures, such as dystonic head tremor
• Multiple sclerosis and cerebellar disease: a tremor that worsens as the hand approaches a target

Diagnosis

There is no single test. A neurologist diagnoses essential tremor from:

• history: when it started, family history, what makes it better or worse, alcohol response, medicines
• examination: observing the tremor at rest, with arms outstretched, during finger-to-nose testing, drawing spirals and writing, and checking for features of Parkinson's or other conditions

Tests are used to exclude other causes: thyroid blood tests, blood sugar, liver and kidney tests, and sometimes copper studies in younger people. A DaTscan can help separate essential tremor from Parkinson's when it is unclear.

Treatment

Treatment is only needed if the tremor bothers you or affects daily life.

Lifestyle measures

• reduce caffeine and other stimulants
• get enough sleep and manage stress
• use weighted utensils, cups with lids, straws, weighted wrist bands, and voice-activated devices
• use both hands, brace your elbow on a table, and write with thick pens

Medicines

• Propranolol, a beta blocker: one of the two first-choice medicines. Not suitable for people with asthma or certain heart conditions.
• Primidone, an anti-seizure medicine: the other first-choice medicine. Started at a low dose to avoid drowsiness and unsteadiness.
• Second-line options: topiramate, gabapentin, and some others.
• About half of people get meaningful benefit from medicines, often reducing the tremor rather than stopping it.

Botulinum toxin injections

Useful for head and voice tremor, and sometimes hand tremor, though it can cause temporary weakness.

Procedures for severe tremor

• Deep brain stimulation (DBS): electrodes placed in the thalamus deliver electrical pulses from a pacemaker-like device. It greatly reduces tremor in most suitable candidates and can treat both sides.
• MRI-guided focused ultrasound thalamotomy: an incisionless procedure that uses focused sound waves to create a tiny lesion in the thalamus. It is usually done on one side.
• Wearable peripheral nerve stimulation devices on the wrist help some people.

Living with essential tremor

Essential tremor is usually slowly progressive but does not shorten life. It can cause embarrassment, anxiety and social withdrawal. Occupational therapy, support groups, and treating anxiety improve quality of life. Some older adults with long-standing essential tremor develop mild balance problems or hearing loss.

Frequently asked questions

What is essential tremor?

Essential tremor is a common neurological condition that causes involuntary, rhythmic shaking, mostly of the hands during activities like writing or drinking. It can also affect the head and voice. It often runs in families and slowly worsens over time.

How is essential tremor different from Parkinson's disease?

Essential tremor happens during movement or when holding a position and usually affects both hands. Parkinson's tremor mainly occurs at rest, often starts on one side, and comes with slowness, stiffness and walking changes.

What triggers essential tremor to get worse?

Stress, anxiety, fatigue, caffeine, hunger, cold, heat and some medicines make essential tremor worse. Many people notice it more when tired, in social situations, or when trying to do fine tasks in front of others.

What is the best treatment for essential tremor?

Propranolol and primidone are the first-choice medicines and help about half of people. Botulinum toxin helps head and voice tremor. For severe tremor, deep brain stimulation or focused ultrasound can be very effective.

Is essential tremor serious?

It is not life-threatening and does not turn into Parkinson's disease, but it can be disabling, making eating, writing and work difficult. It usually progresses slowly. Effective treatments and practical aids help most people manage well.