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Introduction
Essential tremor (ET) is characterised by a symmetrical tremor of the voluntary muscles in the absence of any other neurological signs or symptoms.1 It is generally considered a progressive disorder, however, many patients can experience mild symptoms throughout life.2
ET is one of the most common movement disorders, and it is estimated that over 1,000,000 people in the UK are living with this condition.3-4 It is 8-10 times more prevalent than Parkinson’s disease.2
Aetiology
The underlying cause of ET remains unknown. There are several theories. The most widely accepted is the neurodegeneration hypothesis, whereby there is degeneration within the cerebellothalamocortical circuit, causing the symptoms of tremor.5
Risk factors
ET is an inherited condition in 50-70% of cases, often in an autosomal dominant pattern, and ET cases with a genetic link often present earlier in life.1, 3 It can also be idiopathic.
It is more common with increasing age and occurs equally in men and women.1, 3
Clinical features
History
Patients typically experience a fine, bilateral and symmetrical tremor which can affect any of the voluntary muscles, such as the hands, head, legs, trunk, or voice.2, 6
The tremor often worsens with movement, improves with alcohol, and is absent during sleep. Severity can range from subtle to severe.2, 6
Other important areas of the history to cover include:
- Past medical history: history of known tremor or other movement disorder
- Drug history: drug-induced tremor must be excluded
- Family history: first-degree relatives with ET
- Social history: including alcohol and drug use. Alcohol withdrawal can be a common cause of tremor. It is important to ask about the patient’s living situation, mobility, carers and activities of daily living.
Clinical examination
A thorough examination should be performed, including assessment of cerebellar signs and an upper and lower limb neurological examination.
Typical findings on neurological examination include:6
- A bilateral and symmetrical tremor which typically worsens with voluntary movement, e.g. holding arms outstretched, drinking, writing.
- A resting tremor in some cases
- A nodding head tremor (in a “yes-yes” or “no-no” pattern) or a quivering voice in some patients
Differential diagnoses
Differential diagnoses to consider in the context of ET include:
- Parkinsonism: including Parkinson’s disease, multiple system atrophy (MSA), progressive supranuclear palsy (PSP), vascular parkinsonism or drug-induced parkinsonism
- Hyperthyroidism
- Anxiety
- Huntington’s disease
- Wilson’s disease
- Cerebellar disease: typically causes an intention tremor e.g. worsening tremor when reaching for an object
Table 1. Key differences between essential tremor, Parkinson’s tremor and cerebellar tremor (intention tremor)
| Essential tremor | Parkinson’s tremor | Cerebellar tremor |
| Symmetrical | Asymmetrical | Asymmetrical |
| Better at rest | Worse at rest | Better at rest |
| Worse with voluntary movements | Better with voluntary movements | Worse with voluntary movements |
| Improves with alcohol | No improvement with alcohol | Improves with alcohol |
Investigations
ET is typically a clinical diagnosis, and no investigations are required. However, investigations may be carried out to exclude other differential diagnoses.
Laboratory investigations
Relevant laboratory investigations include:
- Thyroid function tests: to exclude thyroid disorders, if suspected
- Serum ceruloplasmin: to exclude Wilson’s disease, if suspected1
Imaging
Relevant imaging investigations include:
- Neuroimaging (CT/MRI head): can exclude other neurological causes for tremor, but is not routinely required
- Dopamine transporter (DaT) scan: can be used to distinguish between ET (negative) and Parkinson’s disease (positive). This is an expensive test and is only performed in cases of diagnostic uncertainty.1
Management
There is no cure for ET, and current treatment does not halt or reverse the progression of the disease.
Management depends on the tremor’s impact on either the patient’s functional ability or mental state. If the effect is minimal, treatment is often unnecessary.
Regular or patient-initiated follow-ups can be offered, and treatment can be introduced if the tremor begins to affect the patient’s quality of life.
Conservative management
Conservative management may include:
- Occupational therapy: to provide special plates and cutlery which can make eating easier
- Speech and language therapy (SALT): to assist, particularly with vocal tremors, by teaching techniques to manage vocal control and stability
- Patient education: particularly on sleep hygiene and high-quality sleep, as tiredness can exacerbate the tremor
- Reducing stress and exposure to stressful situations: stress can exacerbate tremor3
Medical management
Beta blockers, such as propranolol, are typically the first-line treatment.
If ineffective or contraindicated, certain antiepileptic medications, most commonly primidone, can be used as alternatives.1, 3
Surgical management
Surgical management may include:
- Deep brain stimulation (DBS): a specialised treatment that involves surgically implanting electrodes connected to a small pulse-generating device placed under the skin in the person’s upper chest, which sends high-frequency signals to the thalamus. DBS is only considered for patients who meet strict eligibility criteria and whose symptoms are not adequately controlled with medical management.
- MRI-guided focused ultrasound thalamotomy: a minimally invasive procedure where high-frequency ultrasound is used to target specific areas in the thalamus thought to be causing tremor. This treatment is not commonly used and is typically reserved for individuals who are not responsive to medical management and are not eligible for DBS treatment.1, 3
Complications
Complications of ET can include:
- Reduced quality of life
- Psychological impact: increased incidence of anxiety and depression3
Reviewer
Professor Richard Walker
Consultant Geriatrician
Editor
Dr Jamie Scriven
References
- BMJ Best Practice. Essential tremor. 2023. Available from: [LINK].
- National Tremor Foundation. Essential Tremor. Available from: [LINK].
- National Institute of Neurological Disorders and Stroke. Tremor. 2025. Available from: [LINK].
- Ghiani M, Zhuleku E, Appiah K, et al. Epidemiology, treatment patterns, and healthcare resource utilization of patients with Essential Tremor: A retrospective cohort analysis in the United Kingdom. Clinical Practice Research Datalink. 2023. Available from: [LINK].
- Helmich RC, Toni I, Deuschl G, et al. The Pathophysiology of Essential Tremor and Parkinson’s Tremor. Current Neurology and Neuroscience Reports. 2013. Available from: [LINK].
- Shanker V. Essential tremor: diagnosis and management. BMJ. 2019. Available from: [LINK].
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