Essential tremor

Jump to navigation Jump to search

For patient information, click here

Essential tremor
ICD-10 G25.0
ICD-9 333.1
OMIM 190300 602134
MedlinePlus 000762
MeSH D020329

WikiDoc Resources for Essential tremor


Most recent articles on Essential tremor

Most cited articles on Essential tremor

Review articles on Essential tremor

Articles on Essential tremor in N Eng J Med, Lancet, BMJ


Powerpoint slides on Essential tremor

Images of Essential tremor

Photos of Essential tremor

Podcasts & MP3s on Essential tremor

Videos on Essential tremor

Evidence Based Medicine

Cochrane Collaboration on Essential tremor

Bandolier on Essential tremor

TRIP on Essential tremor

Clinical Trials

Ongoing Trials on Essential tremor at Clinical

Trial results on Essential tremor

Clinical Trials on Essential tremor at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on Essential tremor

NICE Guidance on Essential tremor


FDA on Essential tremor

CDC on Essential tremor


Books on Essential tremor


Essential tremor in the news

Be alerted to news on Essential tremor

News trends on Essential tremor


Blogs on Essential tremor


Definitions of Essential tremor

Patient Resources / Community

Patient resources on Essential tremor

Discussion groups on Essential tremor

Patient Handouts on Essential tremor

Directions to Hospitals Treating Essential tremor

Risk calculators and risk factors for Essential tremor

Healthcare Provider Resources

Symptoms of Essential tremor

Causes & Risk Factors for Essential tremor

Diagnostic studies for Essential tremor

Treatment of Essential tremor

Continuing Medical Education (CME)

CME Programs on Essential tremor


Essential tremor en Espanol

Essential tremor en Francais


Essential tremor in the Marketplace

Patents on Essential tremor

Experimental / Informatics

List of terms related to Essential tremor

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Rina Ghorpade, M.B.B.S[2]


Essential tremor is a neurological disorder characterized by shaking of hands (and sometimes other parts of the body including the head), evoked by intentional movements. The exact incidence is unknown, but it is presumed to be the most common type of tremor and also the most commonly observed movement disorder. Essential tremor was also previously known as "benign essential tremor", but the adjective "benign" has been removed in recognition of the sometimes disabling nature of the disorder.

Historic Perspective

The term essentieller Tremor (essential tremor) was first coined by Raymond (France, 1892)[1]. This term gained widespread use among neurologists during the second half of the 20th century to describe the familial cases of tremors.


There is no system to classify essential tremor.


The pathogenesis of essential tremor (ET) is not fully explained. There is a strong genetic component. It has an autosomal dominant pattern of inheritance, and almost 80% of patients have a family history of tremor[2]. The neuropathology of ET remains highly debatable, although some believe that it is localized to brainstem and cerebellum, it is a controversial theory.


Half of the cases are due to gene mutation and transmitted dominantly. There are two main loci: ETM1 and ETM2.[3] The rest are idiopathic. No identifiable and consistent structural abnormality has yet been demonstrated to exist in the nervous system of every person with ET.

A French kindred study found that the Ser9Gly variant of the dopamine receptor D3 (DRD3) was strongly associated with ET in 23 out of 30 families studied.[4]

Differential Diagnosis

The following table distinguishes ET from other major tremor disorders.

No. Tremor type Type Age

at onset

Frequeny Unilateral/


Symmetry Exacerbating






1) ET Action Bimodal

2nd, and

6th decade

6-12 HZ Bilateral Asymmetric Caffeine, stress Alcohol Mild gait difficulties

in the minority of patients

Hands, head,

and voice

2) Parkinson Disease (PD) Rest > 50 4-6 HZ Unilateral Asymmetric Rest Purposeful


Rigidity, Bradykinesia Hands, legs,


3) Physiologic tremor

(Not visible under normal


Action Can occur at

any age

8-12 Hz Bilateral Symmetrical Stress, anxiety,

Fever, hypoglycemia,

Alcohol, Variety of

drugs, opioid withdrawal, Hyperthyroidism

Removal of cause Depends on the cause. Usually upper extremities, tongue and voice


ET is the most common form of action tremor, and has bimodal age at onset in the second and in the sixth decade of life. The prevalence is usually same for the both genders. The world-wide prevalence for all age is 1%[5].

Risk Factors

1) Family history

2) Age: age above 40 is considered as a risk factor.


There is no available screening test to diagnose ET.

Natural History, Complications, and Prognosis

Natural history

ET is a progressive disease, and it usually worsens gradually over time.


Patients usually have psychological consequences such as anxiety and depression as they tend to avoid social events and stressful situations. Some patients usually have mild cognitive difficulties. It can affect activities of daily living such as holding tools/utensils and equipment, also writing can be significantly affected.


The course of ET is usually stable, however, ET may be associated with an increased risk for developing Parkinson's disease[6].


Diagnostic Criteria

The International Parkinson and Movement Disorder Society (IPMDS) task force defines ET by the following four features[7].

1) Isolated tremor of bilateral upper limb, without other motor abnormalities.

2) Duration: at least three years

3) Absence of other neurological signs.

4) With or without a tremor in other locations. (for example, tremors of arms, hands, or head)


Tremor Characteristics

The ET is a type of action tremor, which usually affects hands and arms. It often occurs asymmetrically and bilaterally. It can involve the face, voice, and trunk. The frequency of ET is 6-12 HZ. Tremor is initiated by voluntary movements when arms are held in an outstretched position against gravity and is usually amplified by goal-directed movements such as drinking from a glass or finger-to-nose testing. Tremor is absent when the affected body part is fully relaxed and supported by gravity. Lower limb tremor is highly unusual in ET and often suggests Parkinson disease. Essential tremor (ET) generally presents as a rhythmic tremor (6-12Hz) that is present only when the affected muscle is exerting effort (i.e., it is not present at rest). Any sort of physical or mental stress will tend to make the tremor worse, often creating the false impression that the tremor is of psychosomatic origin. It is typical for the tremor to worsen in "performance" situations, such as when making out a check at a checkout stand. ET-related tremors do not occur during sleep, but patients sometimes complain of an especially coarse tremor upon awakening that becomes noticeably less coarse within the first few minutes of wakefulness. Tremor intensity can otherwise worsen in response to fatigue, strong emotions, low blood sugar, cold, caffeine, lithium salts, some antidepressants, or other factors. It is often relieved by drinking alcohol. In disabling cases, ET can interfere with a person's ability to perform tasks of daily living, including feeding, dressing, and activities of personal hygiene. ET is usually painless, although in some cases tremors of the head or neck cause pain, and writing can become painful quickly for a person with hand tremors who grips a pen tightly in a struggle to maintain control over penmanship. Sometimes people with ET develop a raspy speaking voice while their ET symptoms worsen over time. When this dysphonia occurs, it is true even in cases where the person's tremor symptoms were first noticeable during early childhood and, so, is unlikely to be related to commonplace reductions in quality that can gradually affect the speaking voices of some elderly people. People with ET often report a progressive decline in their sense of balance and fine motor skills.

Neurological signs

Sometimes individuals may show ataxia, abnormal gait, cognitive deficits, personality changes, and depression. ET affects the activities of daily living and quality of life.

Physical Examiniation

The prominent symptom of ET is asymmetric, postural tremor affecting upper extremities. It can affect head and voice, but rarely lower extremities. Tone and reflexes are usually normal. The minority of patients may have difficulties with gait and balance.

Laboratory findings

There is no signings lab abnormality seen in patients of ET. Routine lab tests such as Thyroid functions tests, electrolytes are done to rule out physiological tremor.


Structural brain imaging such as CT scan or MRI is not required in patients of ET. Striatal dopamine transporter imaging single-photon emission computed tomography (SPECT; DaTscan) can be used to distinguish ET from parkinson disease, Lewy body dementia, and multiple system atrophy. It is usually normal in patients with ET, and it is not generally indicated to diagnose ET. However, it can be useful if it is difficult to differentiate ET from Parkinson's disease.


Drug treatment may include tranquilizers, beta-blockers, and antiepileptic drugs. Surgical treatments (which are generally reserved for the most severe cases) include botulism toxin injections into the affected muscles, thalamotomy, pallidotomy, and deep brain stimulation – the insertion of a brain pacemaker.

The two medications that are prescribed most commonly for control of ET symptoms are the anticonvulsant Primidone (Mysoline) and the beta-blocker propranolol (Inderal).

Minor cases of ET can be treated with physical therapy and development of the muscles in the sections of the body that are severe in their shaking.

Other potential sources of tremor (excessive caffeine consumption, recreational drug use, medications, hyperthyroidism) should be excluded if possible

Support groups

The International Essential Tremor Foundation (IETF) provides information, services, and support to individuals and families affected by essential tremor (ET). The organization encourages and promotes research in an effort to determine the causes, treatment, and ultimately the cure for ET. The IETF is a worldwide organization dedicated to meeting the needs of those whose daily lives are challenged by ET. IETF, an international non-profit 501(c)(3) organization that derives its support entirely from its membership and the general public, was founded in 1988 and is guided by a board of directors and a medical advisory council. The organization's membership consists of patients, physicians, educators, parents, relatives and volunteers who provide education, community services, and funding to help support tremor research.

The National Tremor Foundation (NTF), founded in 1992, is a British friendly organization based in Essex, England, an affiliate of the International Tremor Foundation, which was founded in 1988. The organization's primary work is the production of a quarterly informational newsletter. The NTF also maintains a list of ITF medical advisors and facilitates the formation of self-help groups. NTF was granted charitable status in 1994.

Help with Technology

Tunic Software has released software to help people with essential tremor, Parkinson's Disease, and other causes of hand tremor control their computer mouse. Called 'MouseCage', the software automatically smooths mouse cursor motion to reduce the effects of unsteady or shaky hands.- anti-tremor mouse software

IBM created a peripheral device that filters out tremoring movements of the hand. The hardware adapter, termed AMA, is connected between the computer and the input device. It is switched on or off and adjusted for tremor severity right on the device.

IBM also offers a free smoothing mouse driver for windows 2000 and XP which uses the same technology that helps steady the image in a hand held camcorder. See

Another option is

Other tools have also been adapted for people with tremors; for example, eating utensils which are weighted to help damp out tremor.


  1. Louis ED, Broussolle E, Goetz CG, Krack P, Kaufmann P, Mazzoni P (2008). "Historical underpinnings of the term essential tremor in the late 19th century". Neurology. 71 (11): 856–9. doi:10.1212/01.wnl.0000325564.38165.d1. PMC 3461999. PMID 18779514.
  2. Louis ED, Dogu O (2007). "Does age of onset in essential tremor have a bimodal distribution? Data from a tertiary referral setting and a population-based study". Neuroepidemiology. 29 (3–4): 208–12. doi:10.1159/000111584. PMC 2824583. PMID 18043006.
  3. Kovach M, Ruiz J, Kimonis K; et al. (2001). "Genetic heterogeneity in autosomal dominant essential tremor". Genet Med. 3 (3): 197–9. PMID 11388761.
  4. Jeanneteau F, Funalot B, Jankovic J; et al. (2006). "A functional variant of the dopamine D3 receptor is associated with risk and age-at-onset of essential tremor". Proc Natl Acad Sci U S A. 103 (28): 10753&ndash, 8. PMID 16809426.
  5. Louis ED, Ferreira JJ (2010). "How common is the most common adult movement disorder? Update on the worldwide prevalence of essential tremor". Mov Disord. 25 (5): 534–41. doi:10.1002/mds.22838. PMID 20175185.
  6. Benito-León J, Louis ED, Bermejo-Pareja F, Neurological Disorders in Central Spain Study Group (2009). "Risk of incident Parkinson's disease and parkinsonism in essential tremor: a population based study". J Neurol Neurosurg Psychiatry. 80 (4): 423–5. doi:10.1136/jnnp.2008.147223. PMID 19289477.
  7. Bhatia KP, Bain P, Bajaj N, Elble RJ, Hallett M, Louis ED; et al. (2018). "Consensus Statement on the classification of tremors. from the task force on tremor of the International Parkinson and Movement Disorder Society". Mov Disord. 33 (1): 75–87. doi:10.1002/mds.27121. PMC 6530552 Check |pmc= value (help). PMID 29193359.

Template:Diseases of the nervous system