Essential Tremor

Overview

What is essential tremor?

Essential tremor (ET) is a movement disorder most recognized by uncontrollable shaking (tremors) in different parts and on different sides of the body. Areas affected often include the hands, arms, head, larynx (voice box), tongue, chin and other areas. In rare cases, the lower body is affected.

Symptoms and Causes

What are the symptoms of essential tremor?

The main symptoms associated with essential tremor include:

  • Uncontrollable shaking that occurs for brief periods of time.
  • A shaking voice.
  • Nodding head.
  • Tremors that worsen during periods of emotional stress.
  • Tremors that worsen with purposeful movement.
  • Tremors that lessen with rest.
  • Balance problems, in rare cases.

If it is not essential tremor, what could it be?

Tremors can be caused by a variety of other conditions or lifestyle factors. What separates them is the timing of the tremor. It is important to know if the tremors occur at rest, with sustained posture, or with certain movements.

  • Drugs. There are several drugs that can cause tremor:
    • Albuterol (an asthma drug sold under the brand name Proventil® or Ventolin®).
    • Corticosteroids (like prednisone).
    • Lithium (especially when combined with an antidepressant).
    • Reglan®.
    • Cyclosporine.
    • Antiarrhythmic drugs (like Cordarone®, Procanbid®).
    • Alcohol (chronic use).
    • Tegretol® (a seizure drug, especially when combined with lithium).
    • Nicotine.
    • Dilantin® (a seizure drug).
    • Cocaine.
    • Ritalin®.
    • Sudafed®.
    • Certain antidepressants like Paxil®, Prozac®, Zoloft®, Pamelor®, and others.
  • Other causes:

Diagnosis and Tests

How is essential tremor diagnosed?

If you are having symptoms of essential tremor (ET), you should seek the care of a qualified neurologist. During this evaluation, your doctor will ask you questions about your health, your family medical history, medicines you may be taking, and any surgeries you have had. The evaluation also will be important to determine if there are any factors that worsen or alleviate the tremor.

The doctor will perform a thorough evaluation, noting what part of your body is affected by tremor, when it occurs, and if there is evidence of other features that could indicate a movement disorder other than ET. Imaging tests such as MRI and CT scans are not helpful in diagnosing essential tremor, but may be performed to rule out other possible tremor causes.

Management and Treatment

Can surgery treat essential tremor?

Surgery should be considered for patients with disabling tremor that is not adequately controlled with drug therapy.

The proven surgical treatments are:

Patients who cannot undergo surgery include those who have medical conditions other than essential tremor (ET) that make them poor surgical candidates and those with a significant loss of thinking ability.

Surgical procedures allow patients to potentially reduce their tremor medicines.

When are drugs prescribed to treat essential tremor (ET)?

When essential tremor (ET) often prevents with daily activities, long-term drug treatment is needed. Your healthcare provider will determine which treatment is best based on other medical conditions you may have and based on the safety of the drugs. The goal is to minimize the side effects of drugs while having improvement in function.

With the use of medication, patients may see improvement in the ability to control tremor and improvement in functions like drinking from a cup or using food utensils. More specialized motor functions, such as being able to thread a needle, may not improve.

For patients with mild ET, the effects of the condition can be lessened by the patient’s minimizing exposure to emotional stress and avoiding substances, such as caffeine and nicotine that may increase tremor. In social situations, a person with mild tremor can take a beta blocker drug (see below) or drink a small amount of alcohol if such treatments are approved by a doctor.

Drugs most commonly used to treat ET include beta blocking drugs Inderal® (propranolol), Tenormin® (atenolol), Betapace® (sotalol), and Lopressor® (metoprolol).

Beta blockers

The beta blocker Inderal has been used to treat ET for more than 40 years. It is not clear how Inderal reduces tremors, but the drug may work by blocking nerve impulses to the muscles. Approximately 50 to 60% of patients experience some improvement in functional disability, but total tremor suppression usually is not achieved. The greatest improvement is in hand tremors and voice tremor. The drugs may be taken once a day (for a longer-acting formulation) or twice a day depending upon the formulation used.

Side effects

Beta blockers are not right for everyone. Side effects may include:

  • Slowing heart rate
  • Fainting
  • Fatigue
  • Erectile dysfunction
  • Depression

Some of these side effects may require that the treatment be stopped.
Be sure to tell your doctor if you:

  • Have asthma or other bronchial conditions; beta blockers may cause asthma symptoms
  • Have coronary artery disease or certain heart arrhythmias
  • Have kidney disease
  • Have liver disease
  • Have diabetes
  • Are pregnant or nursing

Facts about drugs

Inderal (propranolol): While you are taking the beta blocker Inderal, your healthcare provider will monitor your heart rate and blood pressure regularly. If you have no significant side effects, you can ask for the longer-acting version. In general, Inderal works over a long period of time to suppress tremors; however, about 10% of people will develop tolerance to the drug after a year. This means that the drug stops being effective in the patient when given in the same dose as when the patient began treatment.

Mysoline® (primidone): Mysoline is an anti-seizure drug that is also effective for treating essential tremor. It is not clear how it works. Mysoline appears to be as effective as Inderal, with significant suppression of tremor in most patients. This medication is most useful for those with hand tremor. The duration of effect from one dose is 24 hours. As with Inderal, a percentage of people may develop tolerance to the treatment after a year.

In most cases, Mysoline is given to patients who do not tolerate propranolol. Mysoline also can be given in addition to Inderal to improve symptomatic relief. Some side effects of Mysoline may occur in the short term (within the first few days of starting treatment); however, these side effects lessen with longer use. Mysoline may cause:

  • Difficulty walking
  • Dizziness
  • Nausea
  • Sleepiness
  • Confusion
  • Fatigue

Serious complications with the drug are rare and include blood cell and bone marrow problems. Your healthcare provider will check your blood counts every 6-12 months to screen for these problems. Mysoline has a drug interaction with phenobarbital, so use caution if the drugs are taken together.

Before taking Mysoline, be sure to tell your doctor if you:

  • Are pregnant or nursing
  • Are taking oral contraceptives (brand names include Ortho-Novum® and Triphasil®) that contain the hormone estrogen
  • Have kidney or liver problems
  • Are taking blood-thinning drugs ( Coumadin®, Panwarfin®, doxycycline, corticosteroids and Griseofulvin®)

In addition, you should avoid alcoholic beverages while taking Mysoline. Do not stop taking the drug suddenly or switch brands without first consulting your healthcare provider.

Neurontin® (gabapentin): Experts use Neurontin for short-term treatment of ET affecting the hands, but it is not known how the drug works. In most cases, it is not used in conjunction with other drugs.
Side effects are rare but include:

  • Sedation
  • Walking difficulties
  • Irritability
  • Weight gain

Alcohol: Some people with ET report symptom relief after drinking a glass of wine or a cocktail. The effect usually lasts about an hour, but rebound tremors occur after this time. It is generally not recommended that you attempt to treat ET symptoms with alcohol.

Benzodiazepines: Benzodiazepines (brand names Xanax®, Klonopin®, Valium®, and Ativan®) may help patients whose ET is not improved by other drugs. These medications appear to relieve tremors associated with emotional stress or anxiety. Side effects of benzodiazepines include confusion, memory loss, and sedation.

Botulinum Toxin: Botox® (subtype A) and Myobloc® (subtype B) are the brand names for botulinum toxin, which can be used to treat some movement problems. The drugs work by paralyzing muscles to reduce tremor. In experienced hands, the drug also can be used to treat voice or head tremors. This treatment consists of an injection into muscle tissue once every three months. Do not take this drug if you are pregnant or if you have myasthenia gravis, post-polio syndrome, or Eaton-Lambert syndrome. Side effects are rare but may include muscle weakness or loss of appetite.

Are there alternative therapies for essential tremor?

Currently, there is no evidence that alternative therapies are beneficial in treating ET. Patients who have tremors that worsen with emotional stress may find relaxation therapies helpful. However, this type of alternative therapy is not a treatment. Some herbal supplements may make tremor worse. Always consult your doctor before trying any alternative therapy.

Can essential tremor be cured?

There is no cure for ET, but treatments that provide relief from its symptoms may be helpful in improving quality of life. These include medications that ease tremor. Not every treatment or procedure is effective for every person with ET. Your doctor will recommend an individualized treatment plan, including certain lifestyle changes that may help to reduce your tremors.

Living With

What should I know about living with essential tremor (ET)?

Essential tremor (ET) is not life-threatening, but it can be very distressing for people who have it. The distress is more acute for people with severe symptoms. Simple activities such as eating, writing, or picking up a cup can be challenging and frustrating.As the disease progresses and tremors become more pronounced, many people feel anxious and embarrassed in social situations, making those situations worse. Eating a forkful of food without spilling, drinking a glass of water in a restaurant, speaking in a meeting without a trembling voice, or writing a legible check can become trying tasks.Some people with ET may feel tempted to withdraw from family and friends, but avoiding social situations is not recommended. There are practical tips, in addition to doctor-prescribed treatments, that allow people with ET to maintain active social lives. Staying socially active is an important part of maintaining emotional and physical well-being.

Educate yourself and others

  • Become informed about your condition and learn as much as you can about living with it.
  • Take an active role in your treatment, and discuss your symptoms and questions with your doctor. The more you know about your condition and its treatment, the easier it will be for you to adapt to the condition in daily living.
  • Explain your condition simply and honestly to people you meet. This will avoid confusion on their part and embarrassment on yours.

Day-to-day tips

  • Find ways to reduce stress and relax.
  • Avoid alcohol consumption. While small amounts of alcohol seem to relieve tremors in some patients, alcohol may interact with medications used to treat ET. In addition, alcohol may have negative effects like alcohol dependency disorder or liver damage. Most experts do not recommend its use.
  • Ask your doctor about whether you should take a small dose of medication, such as a beta-blocker, before a social outing in order to minimize tremors.
  • Ask your doctor about briefly discontinuing certain prescriptions right before you attend social events. Some medications, like thyroid or asthma treatments, may aggravate tremors.
  • Avoid caffeine, which may be found in sodas, coffee, or other drinks/foods.
  • Place a napkin between a cup and a saucer to prevent the cup from rattling.
  • Avoid uncomfortable postures and actions.
  • When using the telephone, press auto dial or have the operator place the call.
  • Add a small amount of weight to your wrist by wearing a heavy bracelet or watch, or by holding something in your hand. The weight may reduce some tremors and restore more control to your hands.
  • Drink beverages from half-filled cups or glasses; use a straw.
  • Get enough rest and sleep as fatigue may make tremors worse.

Resources

  • IETF (International Essential Tremor Foundation). The International Essential Tremor Foundation (IETF) was created to provide 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.
  • International Parkinson and Movement Disorder Society. International Parkinson and Movement Disorder Society is a society that is committed to improve the care of movement disorder patients through education and research. The society is built up by clinicians, scientists and other healthcare professionals.
  • The Parkinson's Institute and Clinical Center. The Parkinson's Institute is an independent, not-for-profit organization conducting patient care and research activities in movement disorders. The Institute's mission is to find the cause and cure for these disorders, to investigate better treatment and diagnostic tools, and to develop prevention strategies.

Last reviewed by a Cleveland Clinic medical professional on 11/20/2019.

References

  • Genetics Home Reference. . Accessed 6/2/2020.Essential tremor (http://ghr.nlm.nih.gov/condition/essential-tremor)
  • Xia Y. Chapter 43. Movement Disorders. In: South-Paul JE, Matheny SC, Lewis EL. eds. CURRENT Diagnosis & Treatment in Family Medicine, 3e. New York, NY: McGraw-Hill; 2011.
  • International Essential Tremor Foundation. . Accessed 6/2/2020.Essential tremor (ET) patient handbook (http://www.essentialtremor.org/wp-content/uploads/2014/04/PatientHandbook02122014PrintWeb.pdf)
  • Pal PK. Ann Indian Acad Neurol. Jul 2011; 14(Suppl1): S25–S28. . Accessed 6/2/2020.Guidelines for management of essential tremor (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3152172/#!po=62.5000)

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