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Neurology

Essential tremor

Essential tremor is an isolated, usually bilateral upper-limb action tremor lasting at least 3 years, diagnosed clinically after characterising the tremor and excluding parkinsonism, dystonia, ataxia, drugs and systemic causes.

In a nutshell

Essential tremor is an isolated bilateral upper-limb action tremor lasting at least 3 years, with or without head or voice tremor and without definite parkinsonism, dystonia or ataxia. It is diagnosed clinically. Treat functional impact with practical measures, propranolol or primidone when appropriate, and refer severe medication-refractory disability to a movement-disorder MDT.

Classic presentation

An adult has years of bilateral hand shaking when holding a cup or writing, with no bradykinesia, rigidity, gait change or dystonia; family history or alcohol responsiveness may be present but is not required.

Key points

  • Established essential tremor is bilateral upper-limb action tremor lasting at least 3 years, without another neurological syndrome.
  • Head or voice tremor may accompany essential tremor; isolated head or voice tremor is not enough for the diagnosis.
  • Family history and improvement with alcohol are supportive clues, not diagnostic criteria, and alcohol is not treatment.
  • Assess rest, posture, action, writing or spiral drawing, tone, bradykinesia, gait, coordination, dystonia and functional impact.
  • Do not routinely image a classic stable syndrome; investigate thyroid, medicines and Wilson's disease only when the context warrants it.
  • Propranolol or primidone are the main UK first-line drug options; check contraindications, interactions and adverse effects.
  • Deep-brain stimulation and selected MR-guided focused ultrasound are specialist options for medication-refractory disability within current UK criteria.
  • Reassess the diagnosis if rapid progression, asymmetry, rest tremor, bradykinesia, rigidity, dystonia, ataxia or other neurological signs appear.

First-line investigation

Clinical tremor and neurological examination with medication and systemic review; use targeted blood tests or specialist imaging only for atypical or uncertain presentations.

Management

Confirm the tremor pattern and red flags

  • Characterise rest, postural and kinetic tremor and examine for bradykinesia, rigidity, dystonia, ataxia, gait change, rapid progression and functional impact.1,2

Address reversible causes and practical function

  • Review medicines, caffeine, anxiety, alcohol withdrawal and systemic causes; offer practical adaptations and occupational-therapy support when needed.1,3

Use propranolol or primidone when impact justifies treatment

  • Choose propranolol or primidone according to comorbidity and preference, titrate under current BNF or local formulary guidance, and monitor pulse, blood pressure, sedation, dizziness, ataxia and cognitive effects.3,4

Measure function and review the diagnosis

  • Assess meaningful functional benefit and adverse effects, and reassess if the tremor develops asymmetry, rest tremor, bradykinesia, rigidity, dystonia, ataxia or rapid progression.1,2

Refer severe refractory tremor to a specialist MDT

  • Discuss deep-brain stimulation or selected MR-guided focused ultrasound only after appropriate medication trials and within current NHS England commissioning and NICE governance criteria.5,6

Support long-term participation and safety

  • Follow progression, work and daily activities, mood, cognition, falls, medication safety and patient goals; arrange movement-disorder review when diagnosis or function remains uncertain.1,3

Exam traps

  • Essential tremor is an action tremor, but the diagnosis depends on bilateral upper-limb action tremor for at least 3 years and no other neurological syndrome.
  • Alcohol response and a family history are not required, and alcohol should never be recommended as treatment.
  • Parkinson's disease is diagnosed by the whole syndrome, especially bradykinesia, not by rest tremor alone.
  • A normal DaTscan does not establish essential tremor and DaTscan is not a routine test.
  • Consider Wilson's disease in a young patient with tremor and liver, psychiatric, dystonic or other suggestive features.
  • Focused ultrasound is a specialist, criteria-based intervention; do not present it as routine first-line care.

Illustrations

Archimedes spiral in essential tremorPaired Archimedes spirals drawn with each hand, showing marked waviness from an action tremor. Use it to demonstrate an examination task, not as a standalone diagnostic test.Undescribed, Wikimedia Commons · CC-BY-SA-4.0

Key sources

  1. NICE NG127, Suspected neurological conditions: recognition and referral (Current NICE adult tremor-recognition recommendations: recognise symmetrical postural tremor as possible essential tremor and refer suspected parkinsonian, asymmetric or otherwise concerning tremor for neurological assessment)
  2. International Parkinson and Movement Disorder Society consensus statement on the classification of tremors (International specialist classification used because no dedicated current UK essential-tremor guideline was identified: essential tremor is bilateral upper-limb action tremor of at least 3 years with no other neurological syndrome; family history and alcohol response are not required)Updated 1 Jan 2018
  3. NHS Lanarkshire Joint Adult Formulary, drugs used in essential tremor (UK NHS formulary guidance: beta-blockers are generally first-line, primidone is often used when beta-blockers are unsuitable, and pulse and blood pressure should be monitored; section next review due December 2026)Updated 31 Jan 2022
  4. BNF, current prescribing information for propranolol, primidone and specialist tremor treatments (Current UK prescribing source for contraindications, interactions, titration and monitoring; direct access was restricted and the available browser session was unavailable, so unsupported doses were omitted)
  5. NHS England, Transcranial magnetic resonance guided focused ultrasound thalamotomy for treatment of medication-refractory essential tremor (NHS England specialised commissioning policy updated 5 October 2021: routine commissioning for selected medication-refractory patients who are not eligible for deep-brain stimulation, within policy criteria)Updated 5 Oct 2021
  6. NICE HTG474, Unilateral MRI-guided focused ultrasound thalamotomy for treatment-resistant essential tremor (NICE 2018 interventional-procedures guidance: limited efficacy evidence; use only with special arrangements for clinical governance, consent and audit or research)Updated 20 Jun 2018

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.