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Essential tremor

Definition

Essential tremor is a nervous system disorder (neurological disorder) that causes a rhythmic shaking. Essential tremor can affect almost any part of your body, but the trembling occurs most often in your hands especially when you try to do simple tasks, such as drinking from a glass, tying shoelaces, writing or shaving. Essential tremor may also affect your head, voice, arms or legs.

Although usually not a dangerous condition, essential tremor worsens over time and can be severe in some people. It isn't caused by other diseases, although it's sometimes confused with Parkinson's disease. Essential tremor can occur at any age but is most common in people age 40 and older.

Essential tremor test

Illustration showing essential tremor test
Enlarge Image
One test used to evaluate essential tremor involves having you draw a spiral. The spiral on the left was drawn by a hand affected by essential tremor. The spiral on the right was drawn by an ...

Symptoms

Essential tremor signs and symptoms:

  • Begin gradually
  • Worsen with movement
  • Usually occur in the hands first, affecting one hand or both hands
  • Can include a "yes-yes" or "no-no" motion of the head
  • May be aggravated by emotional stress, fatigue, caffeine or extremes of temperature

Essential tremor vs. Parkinson's disease
Many people associate tremors with Parkinson's disease, but the two conditions differ in key ways:

  • Timing of tremors. Essential tremor of the hands usually occurs when you use your hands. Tremors from Parkinson's disease are most prominent when your hands are at your sides or resting in your lap.
  • Associated conditions. Essential tremor doesn't cause other health problems, but Parkinson's disease is associated with a stooped posture, slow movement and a shuffling gait. However, people with essential tremor may sometimes develop other neurological signs and symptoms, such as an unsteady gait (ataxia).
  • Parts of body affected. Essential tremor mainly involves your hands, head and voice. Parkinson's disease tremors usually start in your hands, and may affect your legs, chin and other parts of your body.

Causes

About half of essential tremor cases appear to result from a genetic mutation. This form is referred to as familial tremor. It isn't clear what causes essential tremor in people without a known genetic mutation.

Research has found that changes in specific areas of the brain may contribute to essential tremor.

Risk factors

Known risk factors for essential tremor include:

  • Genetic mutation. The inherited variety of essential tremor (familial tremor) is an autosomal dominant disorder. A defective gene from just one parent is needed to pass on the condition.

    If you have a parent with a genetic mutation for essential tremor, you have a 50 percent chance of developing the disorder yourself.

  • Age. Essential tremor is more common in people age 40 and older.

Autosomal dominant inheritance pattern

Illustration showing autosomal dominant inheritance pattern
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A person with an autosomal dominant disorder in this case, the father has a 50 percent chance of having an affected child with one mutated gene and a 50 percent chance of having an ...

Complications

Essential tremor isn't life-threatening, but symptoms often worsen over time. If the tremors become severe, you may find it difficult to:

  • Hold a cup or glass without spilling
  • Eat normally
  • Put on makeup or shave
  • Talk, if your voice box or tongue is affected
  • Write legibly in your usual style

Preparing for your appointment

You'll likely first discuss your symptoms with your family doctor. He or she may refer you to a doctor trained in brain and nervous system conditions (neurologist) for further evaluation.

Because appointments can be brief, and because there's often a lot to talk about, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment and know what to expect from your doctor.

What you can do

  • Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance.
  • Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
  • Write down key personal information, including any major stresses or recent life changes.
  • Make a list of all medications, vitamins or supplements that you're taking.
  • Ask a family member or friend to come with you, if possible. Sometimes it can be difficult to remember all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
  • Write down questions to ask your doctor, such as what tests or treatments he or she may recommend.

Your time with your doctor is limited, so preparing a list of questions ahead of time will help you make the most of your time together. For essential tremor, some basic questions to ask your doctor include:

  • What's the most likely cause of my symptoms?
  • Are there other possible causes of my symptoms?
  • What kinds of tests do I need?
  • How does essential tremor usually progress?
  • What treatments are available, and which do you recommend?
  • I have other health conditions. How can I best manage these conditions together?
  • Are there any restrictions that I need to follow?
  • Are there any brochures or other printed material that I can take home with me? What websites do you recommend?

In addition to the questions that you've prepared, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

  • Do you have a family history of tremor?
  • Have you ever had a head injury?
  • What parts of your body are affected?
  • Does anything make your tremors better or worse?
  • What medications are you taking?

Tests and diagnosis

To diagnose essential tremor, doctors will review your medical history, family history and symptoms and conduct a physical examination.

There aren't any specific tests used to diagnose essential tremor. Determining the diagnosis is often a matter of ruling out other conditions that could be causing your symptoms. To do this, your doctor may suggest the following tests:

Neurological examination
In a neurological examination, your doctor surveys your nervous system functioning, including checking your:

  • Tendon reflexes
  • Muscle strength and tone
  • Ability to feel certain sensations
  • Posture and coordination
  • Gait

Laboratory tests
Your blood and urine may be tested for several factors, including:

  • Thyroid disease
  • Metabolic problems
  • Drug side effects
  • Alcohol levels
  • Levels of chemicals that may cause tremor

Performance tests
To evaluate the tremor itself, your doctor may ask you to:

  • Drink from a glass
  • Hold your arms outstretched
  • Write
  • Draw a spiral

Essential tremor test

Illustration showing essential tremor test
Enlarge Image
One test used to evaluate essential tremor involves having you draw a spiral. The spiral on the left was drawn by a hand affected by essential tremor. The spiral on the right was drawn by an ...

Treatments and drugs

Some people with essential tremor may not require treatment if their symptoms are mild. But if your essential tremor is making it difficult to work or perform daily activities, you may want to discuss treatment options with your doctor.

Medications

  • Beta blockers. Normally used to treat high blood pressure, beta blockers such as propranolol (Inderal) help relieve tremors in some people. Other beta blockers that may be used include atenolol (Tenormin), metoprolol (Lopressor), nadolol and sotalol (Betapace).

    Beta blockers may not be an option if you have asthma or certain heart problems. Side effects may include fatigue, lightheadedness or heart problems.

  • Anti-seizure medications. Epilepsy drugs, such as primidone (Mysoline), may be effective in people who don't respond to beta blockers. Other medications that may be prescribed include gabapentin (Neurontin) and topiramate (Topamax). Side effects include drowsiness and nausea, which usually disappear within a short time.
  • Tranquilizers. Doctors may use drugs such as alprazolam (Xanax) and clonazepam (Klonopin) to treat people whose tremors are made worse by tension or anxiety. Side effects can include fatigue or mild sedation. These medications should be used with caution because they can be habit-forming.
  • OnabotulinumtoxinA (Botox) injections. Botox injections may be useful in treating some types of tremors, especially head and voice tremors. Botox injections can improve tremors for up to three months at a time.

    However, if Botox is used to treat hand tremors, it can cause weakness in your fingers. If it's used to treat voice tremors, it can cause a hoarse voice and difficulty swallowing.

Therapy
Doctors may suggest you participate in physical or occupational therapy. Physical therapists may teach you exercises to improve your muscle strength, control and coordination.

Occupational therapists may help you to adapt to living with essential tremor. Therapists may suggest adaptive devices to reduce the effect of tremors on your daily activities, including:

  • Heavier glasses and utensils
  • Wrist weights
  • Wider, heavier writing tools, such as wide-grip pens

Surgery
A surgical procedure, deep brain stimulation, may be an option for people whose tremors are severely disabling and who don't respond to medications.

In deep brain stimulation, doctors insert a long, thin electrical probe into your thalamus, the portion of your brain that causes your tremors. A wire from the probe runs under your skin to a pacemaker-like device (neurostimulator) implanted in your chest. This device transmits painless electrical pulses to interrupt signals from your thalamus that may be causing your tremors.

Side effects of surgery may include problems with motor control or speech, problems with balance, headaches and weakness. Deep brain stimulation, however, is very effective for severe essential tremor. Side effects are rare and often go away after some time or adjustment of the device.

Deep brain stimulation

Illustration of deep brain stimulation
Enlarge Image
Deep brain stimulation involves implanting an electrode deep within your brain. The amount of stimulation delivered by the electrode is controlled by a pacemaker-like device placed under the skin in ...

Lifestyle and home remedies

The following actions may reduce or relieve tremors:

  • Avoid caffeine. Avoid caffeine and other stimulants because they can increase your tremors.
  • Use alcohol sparingly or not at all. Some people notice that their tremors improve slightly after they drink alcohol, but drinking isn't a good solution for people with essential tremor. Tremors tend to worsen once the effects of alcohol wear off. Also, larger amounts of alcohol eventually are needed to relieve tremors, which can lead to chronic alcoholism.
  • Learn to relax. Stress and anxiety tend to make tremors worse, and being relaxed may improve tremors. Although you can't eliminate all stress from your life, you can change how you react to stressful situations using a range of relaxation techniques, such as massage or meditation.
  • Make lifestyle changes. Use the hand less affected by tremor more often. Find ways to avoid writing with the hand affected by tremor, such as using online banking and debit cards instead of writing checks. Try using voice-activated dialing on your cellphone and speech-recognition software on your computer. Therapists may offer you other suggestions to adapt to essential tremor in your daily life.
Updated: 2/20/2013

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