II. Epidemiology

  1. Age of onset 20-60 years (bimodal distribution)
    1. Likely has onset for most patients in ages 20-30 years but is mild initially
    2. Later presentation at age 60-70 years coincides with the natural progression in severity
  2. Most common pathologic Tremor cause in world
  3. Incidence over age 60 years: 50 cases per 1000
  4. Causes
    1. Genetic (Autosomal Dominant inheritance)
    2. Sporadic

III. Symptoms and Signs

  1. Postural Tremor (Subset of Action Tremor)
    1. Initially presents as postural distal arm Tremor
    2. Usually bilateral (may be unilateral initially)
    3. Slowly progressive
    4. Rest Tremor is typically not present
      1. May progress to Rest Tremor if severe
  2. Frequency at 4-11 Hz
    1. Slower frequencies proximally
    2. Higher frequencies distally
  3. Distribution
    1. Hands (most commonly affected)
      1. Wrist flexion-extension movement
    2. Head
      1. Forward flexion and extension (Nodding 'Yes')
      2. Lateral rotation (Shaking head 'No')
    3. Can also affect head, voice, Tongue and legs
  4. Provocative
    1. Stress or Fatigue
    2. CNS Stimulant Medications
    3. Ask patient to hold hands out in front of them
    4. Ask patient to draw spiral
      1. Archimedes Spiral drawn (spiral with wavy hands)
  5. Palliative
    1. Small amounts of Alcohol
    2. Rest

IV. Differential Diagnosis

  1. See Tremor
  2. See Postural Tremor
  3. Parkinson's Disease
    1. Rest Tremor affecting extremities

V. Labs: Not indicated unless atypical case

  1. Serum Chemistry Panel including Glucose
  2. Complete Blood Count
  3. Thyroid Stimulating Hormone (TSH)

VI. Management: General Measures

  1. Wrist weights
  2. Alternate hand Postures
    1. Incorporate extended arm
  3. Avoid Alcohol as a therapeutic measure
    1. Transient effect with tolerance developing quickly
    2. Tremors may worsen after the Alcohol effect wears off

VII. Management: Medications - First line

  1. Effective in only 30-50% of Essential Tremor cases
  2. Beta Blocker (preferred)
    1. Most effective for limb Tremors, but will is also effective in head Tremor
    2. Non-selective Beta Blockers (preferred first-line)
      1. Propranolol
        1. Daily use: Propranol LA (Inderal) 80-320 mg daily
        2. Prn use: Propranolol 10-40 mg every 6 to 12 hours as needed
      2. Nadolol or Corgard (preferred Beta Blocker)
        1. Start: 40 mg once daily
        2. Maximum: 240 mg daily
    3. Selective Beta Blockers (alternative in Obstructive Lung Disease)
      1. Atenolol
      2. Metoprolol (Lopressor)
  3. Anticonvulsant: Primidone
    1. Primidone (Mysoline) 25-750 mg qd
      1. Start with half of a 50 mg tablet in the evening
      2. Increase slowly
    2. More adverse effects than Propranolol
      1. Sedation
      2. Nausea
      3. Dizziness or Vertigo
      4. Clumsiness

VIII. Management: Specific Essential Tremor management (not responding to agents above)

  1. Refractory essential hand Tremor
    1. Topirimate starting with 25 mg daily
    2. Benzodiazepines prn
    3. Gabapentin (Neurontin) starting with 300 mg at night
  2. Refractory head and voice Essential Tremor
    1. Medications typically fail for control
    2. Head Tremor
      1. Botulinum Toxin Injection of cervical paraspinal and splenius muscle
    3. Voice Tremor
      1. Botulinum Toxin Injection of thyroarytenoid muscles (ENT and EMG guided)
  3. Severe Refractory Essential Tremor
    1. Medications are unlikely to be effective
    2. Bilateral Deep Brain Stimulation
  4. Primary Writing Tremor
    1. Medications tend to be ineffective
  5. Orthostatic Tremor (high frequency Tremor 13 to 18 Hz)
    1. Benzodiazepines may be effective
  6. References
    1. Ahiskog (2012) Mayo POIM Conference, Rochester

IX. Management: Medications - Other

  1. Other Agents
    1. Calcium Channel Blockers
    2. Carbonic Anhydrase Inhibitors
    3. Gabapentin (Neurontin)
    4. Topiramate
    5. Benzodiazepines
    6. Botulinum Toxin
  2. Experimental Agents
    1. Nimodipine
    2. Mirtazapine
  3. Surgical management in very severe cases
    1. Thalamic Stimulation (Deep Brain Stimulation)
    2. Thalamotomy

X. Prognosis

  1. Indicators of better medication response
    1. Very low amplitude rapid Tremor
    2. Hand Tremor (contrast with head and voice Tremor)
  2. Morbidity associated with impact on job functioning and social embarrassment
    1. Up to 25% of patients change career or retire early due to Essential Tremor

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Ontology: Essential Tremor (C0270736)

Definition (MSH) A relatively common disorder characterized by a fairly specific pattern of tremors which are most prominent in the upper extremities and neck, inducing titubations of the head. The tremor is usually mild, but when severe may be disabling. An autosomal dominant pattern of inheritance may occur in some families (i.e., familial tremor). (Mov Disord 1988;13(1):5-10)
Concepts Disease or Syndrome (T047)
MSH D020329
ICD10 G25.0
SnomedCT 192839001, 632009
English Benign essential tremor, Essential tremor, benign essential tremor, Essential Tremor, Essential tremor (hereditary), Benign Essential Tremor, Benign Essential Tremors, Essential Tremor, Benign, Essential Tremors, Benign, Tremor, Benign Essential, Tremors, Benign Essential, Essential Tremors, Tremor, Essential, Tremors, Essential, Essential Tremor [Disease/Finding], essential tremors, essential benign tremor, essential tremor, benign essential tremor syndrome, benign essential tremors, essential benign tremors, physiological tremor, tremor essential, Essential tremor (finding), Benign essential tremor (disorder), essential; tremor, tremor; essential, Benign essential tremor (disorder) [Ambiguous]
Dutch benigne essentiële tremor, essentiële tremor (erfelijk), essentieel; tremor, tremor; essentieel, essentiële tremor, Benigne essentiële tremor, Essentiële tremor, Tremor, essentiële
French Tremblement familial bénin, Tremblement essentiel (héréditaire), Tremblement essentiel
German gutartiger essentieller Tremor, essentieller Tremor (hereditaer), essentieller Tremor, Essentieller Tremor, Benigner essentieller Tremor
Italian Tremore essenziale (ereditario), Tremore essenziale benigno, Tremore essenziale
Portuguese Tremor essencial (hereditário), Tremor essencial benigno, Tremor essencial, Tremor Essencial Benigno, Tremor Essencial
Spanish Temblor esencial benigno, Temblor esencial (hereditario), temblor esencial (hallazgo), temblor esencial benigno (trastorno), temblor esencial, temblor esencial benigno, temblor esencial benigno (concepto no activo), Temblor esencial, Temblor Esencial Benigno, Temblor Esencial
Japanese 本態性振戦(遺伝性), ホンタイセイシンセン, ホンタイセイシンセンイデンセイ, リョウセイホンタイセイシンセン, 振戦-遺伝性本態性, 振戦-本態性-良性, 振戦-本態性-遺伝性, 遺伝性本態性振戦, 本態性振戦-良性, 良性本態性振戦, 本態性振戦, 家族性振戦, 振戦-遺伝性家族性, 振戦-家族性, 遺伝性家族性振戦, 振戦-本態性
Swedish Essentiell tremor
Czech esenciální tremor, benigní esenciální třes, Esenciální tremor, Esenciální tremor (hereditární), Benigní esenciální tremor
Finnish Essentiaalinen vapina
Russian TREMOR ESSENTSIAL'NYI, TREMOR DOBROKACHESTVENNYI ESSENTSIAL'NYI, TREMOR SEMEINYI, ТРЕМОР ДОБРОКАЧЕСТВЕННЫЙ ЭССЕНЦИАЛЬНЫЙ, ТРЕМОР СЕМЕЙНЫЙ, ТРЕМОР ЭССЕНЦИАЛЬНЫЙ
Korean 본태성 떨림
Polish Drżenie samoistne
Hungarian Essentialis tremor, Essentialis tremor (öröklött), Jóindulatú essentialis tremor
Norwegian Benign essensiell tremor, Essensiell tremor