Essential tremor is the most common movement disorder, causing a rhythmic shaking mainly of both hands during actions such as writing or drinking. It often runs in families, tends to improve with alcohol and slowly worsens with age.
Key symptoms
- Shaking hands when holding a cup, writing or eating
- Head nodding or a shaky voice
- Tremor worse with stress, caffeine or fatigue
- Often improves briefly after alcohol
What you find on exam
- Postural tremor with arms held out and kinetic tremor on finger-to-nose
- Tremor mostly absent at rest
- No rigidity, slowness or shuffling gait
- Spiral drawing and handwriting test
Tests
- Clinical diagnosis
- Thyroid tests to exclude hyperthyroidism
- Review of drugs that cause tremor (lithium, valproate, albuterol)
- DaT scan only if Parkinson disease is uncertain
Treatment basics
- No drug needed if mild; avoid caffeine and other triggers
- First line: propranolol or primidone
- Second line: topiramate or gabapentin
- Severe cases: deep brain stimulation or focused ultrasound thalamotomy
Red flags
- Tremor at rest with slowness or stiffness (Parkinson disease)
- Sudden onset, one-sided, or with other neurologic signs
- Tremor with weight loss, palpitations or sweating (hyperthyroidism)
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.