Essential tremor

Essential Tremor is the commonest movement disorder of adults. It is defined as a bilateral arm tremor although most body parts can be additionally involved. Although previously referred to as “Benign Essential Tremor”, this terminology is not appropriate as for some it is not benign. It becomes more common as we age (around 5% over 65 years) but a younger onset (<24 years) is recognised. It affects men and women equally. Onset and progression are insidious, the arm tremor is characteristically kinetic/action (with or without postural involvement) with a frequency between 8-12 Hz. Whilst the tremor may be asymmetric, it is always bilateral (as opposed to Parkinson’s Disease tremor).

Key Features:

Action tremor (e.g. holding cup or pen)
Affects both arms
Family history and alcohol responsiveness common

Additional manifestations include head tremor (not seen in Parkinson’s Disease), jaw/chin and vocal tremors. Isolated head tremor is more often dystonic than Essential Tremor. About half of patients report alcohol responsiveness and/or a family history. A variety of other neurological symptoms can occur, labelled as “Essential Tremor plus” syndrome.

Whilst progressive, it is not disabling for the majority, but can cause social embarrassment as well as fears of more sinister conditions. A number of drugs can exacerbate or cause tremor.

Do they need investigation in primary care?

All patients with tremor deserve thyroid function testing.

Please note the above information is a summary of management based on BMJ Article: ‘Essential Tremor: Diagnosis and Management’

Who to refer, who not to refer, how to refer

Who to refer?

Refer the following patients to Neurology:

Patients with isolated head tremor (as often dystonic tremor)
Patients with essential tremor plus i.e. other abnormal movements or neurological signs
Patients refractory to treatment

NB all young patients with movement disorders, check Caeruloplasmin levels (on TRAK as ceruloplasmin) and Thyroid function and request optician assessment for KF rings (to exclude Wilson’s disease)

Who not to refer?

See BMJ paper referenced.

How to refer?

Referrals should be completed via SCI Gateway

Primary care management

General Lifestyle Advice

Reassurance, where appropriate, that they do not have a more sinister condition; the most feared is Parkinson’s Disease, which presents with a unilateral, rest tremor as opposed the bilateral kinetic tremor of Essential Tremor.

Avoid stimulants (e.g. caffeine) if noted to exacerbate symptoms. Consider whether Beta agonist inhalers or nebulisers could be a factor and whether there are alternatives. Judicial use of small amounts of alcohol may be appropriate.

Treatment of Essential Tremor

Many will require nothing more than reassurance. Remind the patient that 1 in 20 over 65 years have it and it is rare for it to become disabling. If troublesome, then consider:

First Line therapies

Propranolol MR: start at 80mg/day and this may be increased up to 360mg/day (od) depending on response and tolerability Primidone: start at 25-50mg at night (available as 50 and 250 mg tablets, halving may be difficult for people with tremor). Titrate slowly over at least 4-6 weeks to maximum 750 mg/day as tds dosage although few can tolerate this due to sedation. Many will report that they had to endure several weeks of side effects before ‘getting used’ to being on the drug. Second Line therapies Include topiramate, gabapentin, alprazolam, clonazepam and deep brain stimulation surgery. Our experience with these second line drug therapies is disappointing. In the future MRI guided focused ultrasound may be relevant to those with very disabling tremor. Please see Patient Information The National Tremor Foundation for further information: https://tremor.org.uk/

Second Line therapies (consider carefully whether drug therapy required)

Include topiramate, gabapentin, alprazolam, clonazepam and deep brain stimulation surgery. Our experience with these second line drug therapies is disappointing. In the future MRI guided focused ultrasound may be relevant to those with very disabling tremor.

Resources and links

Patient information The National tremor Foundation https://tremor.org.uk/

Essential Tremor-Triage Support Jan 2020

BMJ Article: Brief summary of management Based on ‘Essential Tremor: Diagnosis and Management’

British National Formulary(BNF) for info on contraindications, cautions, side effects, pregnancy etc

Last reviewed: 16/01/2025

Next review date: 16/01/2027

Author(s): Dr Myles Connor.

Author email(s): myles.connor@nhs.scot.