Essential tremor

Essential tremor is a nervous system condition, also known as a neurological condition. It causes rhythmic shaking that you can’t control. Essential tremor can affect almost any part of the body, but the trembling happens most often in the hands. The trembling occurs especially when doing simple tasks, such as drinking from a glass or tying shoelaces.

Essential tremor usually is not a dangerous condition. However, it typically worsens over time and can be severe for some people. Other conditions don’t cause essential tremor, but essential tremor sometimes is confused with Parkinson’s disease.

Essential tremor can happen at any age but is most common in people age 40 and older.

Essential tremor symptoms:

• Begin gradually. They usually are more noticeable on one side of the body.
• Worsen with movement.
• Usually happen in the hands first, affecting one hand or both hands.
• Can include a “yes-yes” or “no-no” double nodding or shaking motion of the head.
• May worsen with emotional stress, fatigue, caffeine or extreme temperatures.

Essential tremor vs. Parkinson’s disease

Many people link tremors with Parkinson’s disease. But the two conditions differ in important ways, including:

• Timing of tremors. Essential tremor of the hands usually happens when using the hands. Tremors from Parkinson’s disease are most noticeable when the hands are resting at the sides of the body or in the lap.
• Related conditions. Essential tremor doesn’t cause other health problems. However, people with essential tremor sometimes develop other neurological symptoms, such as an unsteady walk. Parkinson’s disease is linked to stooped posture, slow movement and dragging the feet when walking.
• Parts of the body affected. Essential tremor mainly involves the hands, head and voice. Parkinson’s disease tremors usually start in the hands and can affect the legs, chin and other parts of the body.

About half the people with essential tremor appear to have an altered gene. This form of the condition is referred to as familial tremor. It isn’t clear what causes essential tremor in people who don’t have familial tremor.

Known risk factors for essential tremor include:

• Altered gene. The inherited variety of essential tremor, known as familial tremor, is an autosomal dominant disorder. That means an altered gene from just one parent is needed to pass on the condition.

  Anyone who has a parent with an altered gene for essential tremor has a 50% chance of developing the condition.

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

Essential tremor isn’t life-threatening, but symptoms often worsen over time. If the tremors become severe, it might be difficult to:

• Hold a cup or glass without spilling.
• Eat without shaking.
• Put on makeup or shave.
• Talk, if the voice box or tongue is affected.
• Write legibly.

There is no known way to prevent essential tremor.

Diagnosing essential tremor involves a review of your medical history, family history and symptoms, and a physical examination.

There are no medical tests to diagnose essential tremor. Diagnosing it is often a matter of ruling out other conditions that could be causing symptoms. To do this, your healthcare professional may suggest the following tests.

Neurological exam

In a neurological exam, your healthcare professional tests how well your nervous system is working. This may include checking your:

• Tendon reflexes.
• Muscle strength and tone.
• Ability to feel certain sensations.
• Posture and coordination.
• Walk and balance.

Lab tests

Blood and urine may be tested for several factors, including:

• Thyroid disease.
• Metabolic problems.
• Medicine side effects.
• Levels of chemicals that may cause tremor.

Performance tests

To evaluate the tremor itself, your healthcare professional may ask you to:

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

A healthcare professional who still is not sure if a tremor is essential tremor or Parkinson’s disease might order a dopamine transporter scan. This is a special imaging test that uses an injected medicine to show where the chemical dopamine is found in the brain. It can help the healthcare professional tell the difference between the two types of tremors.

Some people with essential tremor don’t require treatment if their symptoms are mild. But if your essential tremor is making it difficult to work or perform daily activities, discuss treatment options with your healthcare professional.

Treatment options may include:

Medicines

• Beta blockers. Typically used to treat high blood pressure, beta blockers such as propranolol (Inderal LA, InnoPran XL, Hemangeol) help relieve tremors in some people. Beta blockers may not be an option for people with asthma or certain heart problems. Side effects may include fatigue, lightheadedness or heart problems.
• Anti-seizure medicines. Primidone (Mysoline) may be effective in people who don’t respond to beta blockers. Other medicines that might be prescribed include gabapentin (Gralise, Neurontin, Horizant) and topiramate (Topamax, Qudexy XR, others). Side effects include drowsiness and nausea, which usually disappear within a short time.
• Tranquilizers. Healthcare professionals may use benzodiazepines such as clonazepam (Klonopin) to treat people whose tremors worsen with tension or anxiety. Side effects can include fatigue or mild sedation. These medicines should be used with caution because they can be habit-forming.

• Nerve-blocking injections. Injections with onabotulinumtoxinA, also known as Botox, might 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 the fingers. If Botox is used to treat voice tremors, it can cause a hoarse voice and difficulty swallowing.

Therapy

Healthcare professionals might suggest physical or occupational therapy. Physical therapists can teach you exercises to improve your muscle strength, control and coordination.

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

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

Nerve stimulation devices

A wearable electronic peripheral nerve stimulation device (Cala Trio, Cala kIQ) is a newer treatment option for people with essential tremor. The device is worn as a wristband for 40 minutes twice a day. It works by stimulating nerves and muscles to create a muscle response that reduces tremors. Studies have found that the device can bring some improvement for tremors.

Surgery

Surgery might be an option if your tremors are severely disabling and you don’t respond to medicines.

• Deep brain stimulation. This is the most common type of surgery for essential tremor. It involves putting a long, thin electrical probe into the part of the brain that causes the tremors, known as the thalamus. A wire from the probe runs under the skin to a device called a neurostimulator that’s placed under the skin in the chest. This device sends painless electrical pulses to interrupt signals from the thalamus that may be causing the tremors.

  Side effects of deep brain stimulation can include equipment malfunction and problems with motor control, speech or balance. Headaches and weakness also may be side effects. After some time or adjustment of the device, side effects often go away.

• Focused ultrasound thalamotomy. This noninvasive surgery involves using focused sound waves that travel through the skin and skull. The waves generate heat to destroy brain tissue in a specific area of the thalamus to stop a tremor. A surgeon uses MRI to target the correct area of the brain and to be sure the sound waves are generating the exact amount of heat needed for the procedure.

  Focused ultrasound thalamotomy is done on one side of the brain. The surgery affects the other side of the body from the one where it’s done.

  Focused ultrasound thalamotomy creates a lesion that can result in permanent changes to brain function. Some people have experienced altered sensation, trouble with walking or difficulty with movement. However, most complications go away on their own or are mild enough that they don’t interfere with quality of life.

To reduce or relieve tremors:

• Avoid caffeine. Caffeine and other stimulants can increase tremors.
• Use alcohol sparingly, if at all. Some people notice that their tremors improve slightly after they drink alcohol, but drinking isn’t a good solution. Tremors tend to worsen once the effects of alcohol wear off. Also, more alcohol eventually is needed to relieve tremors, which can lead to alcohol use disorder.
• Learn to relax. Stress and anxiety tend to make tremors worse. Being relaxed may improve tremors. You can’t rid your life of all stress. But 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 that is less affected by tremor more often. Find ways to avoid writing, such as using online banking and debit cards instead of writing checks. Try voice-activated commands on your smartphone and speech-recognition software on your computer.

For many people, essential tremor can have serious social and psychological consequences. If the effects of essential tremor make it difficult to live your life as fully as you once did, consider joining a support group.

Support groups aren’t for everyone, but you might find it helpful to have the encouragement of people who understand what you’re going through. Or see a counselor or social worker who can help you meet the challenges of living with essential tremor.

You’ll likely start by seeing your primary healthcare professional. Or you might be referred to a doctor trained in brain and nervous system conditions, called a neurologist.

Here’s some information to help you get ready for your appointment.

What you can do

• Be aware of anything you need to do ahead of time. At the time you make the appointment, ask if there’s anything you need to do in advance, such as restrict your diet.
• Write down symptoms you have, including any that may not seem related to the reason you scheduled the appointment.
• Write down important personal information, including major stresses or recent life changes.
• Make a list of all medicines, vitamins and supplements you’re taking and the doses.
• Take a family member or friend along. Sometimes it can be hard to remember all the information provided during an appointment. Someone who goes with you may remember something that you missed or forgot.
• Write down questions to ask your healthcare team.

Your time with your healthcare team is limited, so preparing a list of questions can help you make the most of your time together. List your questions from most important to least important in case time runs out. For essential tremor, some basic questions to ask include:

• What’s the most likely cause of my symptoms?
• Are there other possible causes?
• What 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 restrictions I need to follow?
• Should I see a specialist? If so, whom do you recommend?
• Are there brochures or other printed materials I can have? What websites do you recommend?

Don’t hesitate to ask other questions.

What to expect from your doctor

Be prepared to answer questions, such as:

• When did your symptoms begin?
• 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?