What is essential tremor?

Essential tremor (ET) is a neurological disorder that causes your hands, head, trunk, voice or legs to shake rhythmically. It is often confused with Parkinson's disease.

Essential tremor is the most common trembling disorder. Everyone has at least a small degree of tremor, but the movements usually cannot be seen or felt because the tremor is so small. When tremors are noticeable, the condition is classified as essential tremor.

Essential tremor is most common among people older than 65, but it can affect people at any age. Some experts have proposed considering ET that starts earlier in life as essential tremor and ET that begins later in life as age-related tremor, because the conditions may have different symptoms and may respond differently to treatments.

What causes essential tremor?

The cause of essential tremor is unknown. However, one theory suggests that your cerebellum and other parts of your brain are not communicating correctly. The cerebellum controls muscle coordination.

In most people, the condition seems to be passed down from a parent to a child. If your parent has ET, there is a 50% chance you or your children will inherit the gene responsible for the condition. Sometimes, ancillary testing such as brain imaging or genetic testing may help with the diagnosis.

What are the symptoms of essential tremor?

If you have essential tremor, you will have shaking and trembling at different times and in different situations, but some characteristics are common to all. Here is what you might typically experience:

• Tremors occur when you move and are less noticeable when you rest.
• Certain medicines, caffeine or stress can make your tremors worse.
• Tremors may improve with ingestion of a small amount of alcohol (such as wine).
• Tremors get worse as you age.
• Tremors don’t affect both sides of your body in the same way.

Here are signs of essential tremor:

• Tremors that are most obvious in your hands
• Difficulty doing tasks with your hands, such as writing or using tools
• Shaking or quivering sound in your voice
• Uncontrollable head-nodding
• In rare instances, tremors in your legs or feet

How is essential tremor diagnosed?

The appearance of your tremor, in the setting of a comprehensive neurological examination by an experienced clinician, can result in diagnosis of essential tremor. Your doctor will probably need to rule out other conditions that could cause shaking or trembling. For example, tremors could be symptoms of diseases such as hyperthyroidism. Your health care provider might test you for those as well.

In some cases, the tremors might be related to other factors. To find out for certain, your health care provider may have you try to:

• Abstain from heavy alcohol use — trembling is a common symptom among people with alcohol use disorder.
• Avoid caffeine.
• Avoid or reduce certain medicines.

How is essential tremor treated?

Medications for Essential Tremor

Propanolol and primidone are two of the medicines often prescribed to treat essential tremor.

Propanolol blocks the stimulating action of neurotransmitters to calm your trembling. This beta blocker is effective in 40% to 50% of patients and is less useful in reducing head and voice tremor. It is usually avoided in patients with asthma, emphysema, congestive heart failure or heart block, and should be used with caution by people with diabetes who are on insulin. These drugs may reduce exercise tolerance, lower blood pressure or heart rate, exacerbate depression and cause impotence. Other adrenergic blockers with fewer side effects include atenolol, nadolol, metoprolol and timolol.

Primidone controls the actions of neurotransmitters. Some patients starting primidone may experience a “first dose phenomenon” during which they have transient feelings of unsteadiness, dizziness and nausea during the beginning stages of treatment. This is usually short-lived. Sedation is another common side effect and can be reduced by following a slowly escalating dose schedule. Most patients are able to tolerate the side effects, and studies have shown that 60% to 100% of patients respond positively.

If primidone or propranolol are not effective by themselves, a combination of both may provide relief for some patients.

Gabapentin and topiramate are two other anti-seizure medicines that are sometimes prescribed for essential tremor. In some cases, benzodiazepines such as alprazolam or clonazepam might be suggested.

For essential tremor in your hands, botulinum toxin (Botox) injections have shown some promise in easing the trembling. They work by slightly relaxing the overactive muscles. The injections are targeted to the specific muscles that are involved in the abnormal movement, while avoiding uninvolved muscles. Botox injections are typically recommended for patients with severe head tremor, and several studies have shown that the injections may significantly help head and voice tremors.

Surgery for Essential Tremor

For severe tremors, a stimulating device (deep brain stimulator) surgically implanted in your brain may help.

Natural Remedies for Essential Tremor

People with tremor also may benefit from avoiding dietary stimulants, such as caffeine.

Lifestyle Modifications

Essential tremor is usually not dangerous, but it can certainly be frustrating. Certain factors can make tremors worse, so the following steps may help decrease tremors:

• Avoiding alcohol and caffeine
• Avoiding stressful situations as much as possible
• Using relaxation techniques, such as yoga, deep-breathing exercises or biofeedback
• Checking with your health care provider to determine if any medicines you’re taking could be making your tremors worse

Talk with your health care provider about these and other options, such as surgery, if essential tremor starts to affect your quality of life or if you develop new neurologic symptoms, such as numbness or weakness.

Next steps

Tips to help you get the most from a visit to your health care provider:

• Know the reason for your visit and what you want to happen.
• Write down your questions before your visit.
• Bring someone with you to help you ask questions and remember what your provider says.
• During the visit, write down the name of any new diagnosis, medicines, treatments or tests. Also, write down new instructions.
• Know why a new medicine or treatment is prescribed, and how it will help you. Also, know the side effects.
• Ask if your condition can be treated other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if you do not take a medicine or have a test or procedure.
• If you have a follow-up appointment, write down the date, time and purpose.
• Know how to contact your provider if you have questions.