Essential Tremor: Diagnosis and Management
SUMMARY:
Essential tremor (ET) is a neurological disorder characterized by involuntary shaking or trembling of the hands, head, voice, or other parts of the body. Essential tremor is the most common movement disorder, with an increasing incidence as people age. The pathogenesis of ET is unknown, but there appears to be a strong genetic component and a positive family history is common. Treatment of ET focuses on symptom management to control tremors that interfere with IADLs.
Clinical Presentation
- Patients present with tremor that
- Is bilateral, but may have some asymmetry in degree of tremor
- Affects the upper limbs
- Occurs with action (action tremor) or when limb is held in position against gravity (postural tremor)
- May also affect the voice or head (e.g., yes-yes or no-no head shaking)
- Rarely affects the lower limbs
- Prevalence is the same in men and women and incidence increases with age
- Symptoms are progressive and can be present for years before patients seek medical care
- Family history of ET is common
- Patients may report a history of tremor improving with alcohol use
Diagnosis
- Diagnosis of ET is based on clinical features and requires four features, as outlined by the International Parkinson and Movement Disorder Society (IPMDS)
- Bilateral upper limb action and/or postural tremor
- Present for at least 3 years
- Can occur with tremor in other locations (e.g., head, voice, lower extremities)
- Absence of other neurologic deficits or dysfunction
- Dopamine transporter imaging (DaTscan) can be used to help distinguish between Parkinson Disease and ET when diagnosis is unclear, but is not required for diagnosis
Management
First line therapy
- Propranolol
- Should be considered for treatment of head tremor in patients with ET
- Propranolol long-acting
- Primidone
Second line therapy
- Beta-blockers (e.g., Atenolol, Sotalol)
- Treatment of limb tremor associated with ET
- Nadolol may be considered but strength of recommendation is lower when compared to Atenolol and Sotalol
- Nimodipine
- May be considered when treating limb tremor in patients with ET
- Gabapentin
- Treatment of limb tremor associated with ET as monotherapy
- Topiramate
- Treatment of limb tremor associated with ET
- Benzodiazepines (e.g., Clonazepam, Alprazolam)
- Alprazolam preferred over Clonazepam
- Benzodiazepines should be used with caution due to potential for abuse and withdrawal symptoms when discontinued
Refractory tremor
- Therapies for refractory tremor should involve a neurologist or neurosurgeon with experience with movement disorders
- Botulinum toxin injections may be considered for patients with disabling tremors in specific locations (e.g., voice tremor, tremors of the hand or head)
- Unilateral thalamotomy
- Can be used to treat limb tremor that is refractory to medical management
- Bilateral thalamotomy is not recommended due to adverse events
- Decision to proceed with procedure should be individualized to patient’s disease severity and risk of adverse events
- Deep brain stimulation (DBS)
- May be considered for patients with severe, disabling tremors that are refractory to medication
- Decision to proceed with procedure should be individualized to patient’s disease severity and risk of adverse events
KEY POINTS:
- Essential tremor is a gradually progressive neurologic disease that causes a bilateral action tremor of the upper extremities
- First line therapy for tremor that interferes with daily activities is either primidone or propranolol
- Botox injections may be used for tremor in a specific location that is medically refractory
Learn More – Primary Sources
AAN Update: Treatment of Essential Tremor
