Tremor

What is tremor?

Tremor is a rhythmic movement of a body part that’s out of your control (involuntary). The movements look like trembling or shakiness and can range from mild to severe. They may be constant or only happen sometimes. Tremor is a common symptom of movement disorders.

You can have tremor in one part of your body or multiple parts. It most commonly affects your hands. But it can also occur in your:

• Arms.
• Legs.
• Head, neck or face.
• Vocal cords.
• Torso.

Most people naturally have a slight tremor called a physiologic tremor. You may notice that if you hold your hands or arms out in front of you, they’re not completely still. This is normal and expected. This natural tremor is typically slightly greater when you consume caffeine or alcohol, take certain medications, or are tired or anxious. Aging also tends to make this tremor worse.

Tremor is significant as a medical symptom when it affects your daily activities, like your ability to eat food, walk, dress or work. Some conditions — like essential tremor — only have tremor as a symptom. In other conditions (like Parkinson’s disease and multiple sclerosis), tremor can be one of many symptoms (or features) of them.

Types of tremor

Healthcare providers categorize tremor into two main types based on when and how it starts:

• Resting tremor: This tremor happens in a body part that’s relaxed and completely supported against gravity. For example, if you’re resting and relaxing your arm on a flat surface and it’s shaky, that’s a resting tremor.
• Action tremor: This tremor happens when you’re voluntarily contracting muscles in the affected body part. For example, if you lift your arm and it starts shaking, that’s an action tremor.

Subtypes of action tremors include:

• Postural tremor: This happens when you’re holding a body part in a position against gravity, like holding your arms out in front of you.
• Isometric tremor: This happens during a voluntary muscle contraction that doesn’t involve motion, like holding a heavy object in the same position.
• Kinetic tremor: This happens with voluntary movement (motions), like closing and opening your eyes or lifting your hand to touch your nose.

What causes tremor?

Tremor can have several possible causes, depending on the type and tremor syndrome, including:

• Alcohol use disorder and alcohol withdrawal.
• Brain tumors.
• Certain medications.
• Certain metabolic conditions, like hyperthyroidism, hypocalcemia, hypoglycemia (low blood sugar) and hypomagnesemia. These are typically treatable.
• Certain neurodegenerative conditions, like Parkinson’s disease and multiple sclerosis (MS).
• Stroke.
• Traumatic brain injuries.

What medications cause tremor?

Several medications can cause or worsen tremor. Some examples include:

• Amiodarone (an arrhythmia medication).
• Asthma medications, like fluticasone (Advair®) and albuterol.
• Atorvastatin (Lipitor®).
• Corticosteroids.
• Fluoxetine (Prozac®).
• Lithium.
• Methylphenidate (Ritalin®).
• Second-generation antipsychotics.
• Tricyclic antidepressants.

If you develop tremor — or an existing tremor gets worse — after starting a medication, tell your healthcare provider.

How is tremor diagnosed?

To diagnose tremor, your healthcare provider will do a physical exam and ask questions about your symptoms and medical history. They’ll ask you:

• If the tremor started suddenly or slowly worsened over time.
• Which body parts have tremor.
• If certain factors trigger the tremor, like moving, being at rest or standing.
• If certain factors make the tremor better or worse, like caffeine, stress or distraction.

Your provider will also do a neurological exam. This assesses your neurological functions in general, like your balance, cognition and reflexes. Your provider can also learn more about the characteristics of the tremor with this exam.

Because there are so many forms of tremor, it can be difficult for providers to determine the specific type and cause without further testing. Your provider may recommend several tests to find the underlying cause, like:

• Blood tests.
• Urine (pee) tests.
• EMG and/or nerve conduction studies.
• CT scan or MRI of your brain.

Tremor syndromes

Healthcare providers define and diagnose tremor syndromes based on the pattern of the tremor. Some of the most common forms of tremor include:

• Essential tremor: This is the most common tremor syndrome, affecting 0.4% to 6% of the U.S. population. Its key feature is a tremor in both hands and arms during voluntary movement without other neurological symptoms. It can also affect your head, voice or lower limbs. This tremor is usually a kinetic tremor.
• Cerebellar tremor: Cerebellar tremor typically involves a slow, big tremor of your arms, legs, hands or feet. It worsens at the end of a purposeful movement, like twisting a doorknob. Damage to the cerebellum (part of your brain) and its pathways causes it, often from a stroke, brain tumor, multiple sclerosis or long-term damage due to alcohol use disorder.
• Dystonic tremor: This form of tremor is usually irregular and jerky. Certain hand or arm positions stop the tremor. Other signs of dystonia (like abnormal flexion of your wrists) are always present. Dystonic tremor and dystonia typically develop from damage in your basal ganglia.
• Orthostatic tremor: This involves rapid muscle contractions in your legs that happen when you stand. The tremor usually stops when you sit or walk. The contractions are very fast, so you may not be able to see them. But you can feel the contractions when you touch your thighs or calves. Orthostatic tremor is rare, and the cause is unknown.
• Parkinsonian tremor: More than 70% of people with Parkinson’s disease have Parkinsonian tremor. It’s often the first symptom you get. Parkinsonian tremor is most noticeable when your affected body part is at rest. The tremor may initially appear in only one limb or on just one side of your body, but it can spread to both sides.
• Functional (psychogenic) tremor: This can be any type of tremor. But it often starts suddenly, and the severity fluctuates widely. The movements typically worsen when you’re focused on them and get better when you’re distracted. Psychogenic tremor is a type of functional movement disorder.

What is the treatment for tremor?

The treatment for tremor depends largely on the type and the underlying cause. Tremor that results from brain damage generally isn’t curable. But tremor that happens due to medications, substances or metabolic conditions typically is.

In general, treatments include:

• Cerebellar tremor: No effective medication is available for cerebellar tremor, but physical therapy may help.
• Dystonic tremor: Treatment for dystonic tremor depends on which body part is affected. Options include medication, botulinum toxin (Botox®) injections and deep brain stimulation.
• Essential tremor: Essential tremor isn’t curable, but medications like propranolol or other beta-blockers are often effective, as is primidone. Other treatment options include Botox injections and deep brain stimulation.
• Functional (psychogenic) tremor: Physical therapy is the go-to treatment for this tremor, especially motor (movement) retraining. Other therapies can help as well, like occupational therapy and psychotherapy (talk therapy).
• Orthostatic tremor: Medications like benzodiazepines, beta-blockers and antiseizure medications may help orthostatic tremor.
• Parkinsonian tremor: Levodopa is usually the treatment of choice for Parkinsonian tremor. Your neurologist may also recommend other Parkinson’s disease medications.

If a certain medication or substance (like caffeine or alcohol) is causing or worsening a tremor, stopping the medication (under your healthcare provider’s direction) or substance will likely help your symptoms. Similarly, treatment for metabolic conditions that can cause tremor, like hyperthyroidism, typically makes the tremor go away.

It’s also important to see a mental health specialist (like a psychologist) if tremor is causing you mental distress, like depression, anxiety or social isolation.

What can I do at home to treat tremor?

Aside from getting medical treatment, other steps you can take at home that may make it easier to live with tremor include:

• Eliminating or reducing substance use (like caffeine or alcohol) if it worsens the tremor.
• Using assistive tools, like special eating utensils, to make everyday tasks more manageable.
• Wearing adaptive clothing to make it easier to get dressed, like clothing that has Velcro® instead of buttons.
• Taking your medications on time. If you notice certain medications make the tremor worse, tell your healthcare provider.
• Reducing stress in your life. Stress can make tremor worse.
• Getting enough quality sleep. A lack of sleep can worsen some forms of tremor.
• Joining a support group to learn from and relate to others who experience tremor.

When should I see a healthcare provider about tremor?

See your healthcare provider if:

• Tremor is getting worse over time.
• It’s affecting your daily activities.
• It’s causing you emotional distress.
• You develop other neurological symptoms, like changes in thinking, behavior or muscle strength.

If you have a tremor diagnosis, you’ll likely need to see your provider regularly to make sure your treatment plan is working well.