History

The following characteristics can be noted in patients with essential tremor:

A family history of essential tremor is noted in 50–70% of cases
Tremor usually begins in one upper extremity and soon affects the other; essential tremor rarely extends from the upper extremity to the ipsilateral leg
A mild degree of asymmetry is not unusual
In about 30% of cases, tremor involves the cranial musculature; the head is involved most frequently, followed by voice, jaw, and face
Tremor may be intermittent initially, emerging only during periods of emotional activation
Over time the tremor becomes persistent
At any point in time, the frequency of the tremor is relatively fixed
The amplitude of the tremor is highly variable, depending on the state of emotional activation; tremor amplitude is worsened by emotion, hunger, fatigue, and temperature extremes
The baseline tremor amplitude slowly increases over years
A degree of voluntary control is typical, and the tremor may be suppressed by skilled manual tasks
The tremor resolves during sleep
Ethanol intake temporarily reduces tremor amplitude in an estimated 50–70% of cases

Visible tremor is generally pathologic, but distinguishing between essential tremor and enhanced physiologic tremor can be difficult. Causes of enhanced physiologic tremor, including medications, stimulants such as caffeine, hyperthytoidism, fever, and anxiety, and should be excluded.

Physical Examination

Essential tremor is considered to be monosymptomatic (tremor only), although some patients have abnormalities in gait and balance. If patients have such abnormalities, the diagnosis should be carefully considered because these could be clues to an alternative diagnosis.

The tremor is characteristically postural (occurring with voluntary maintenance of a position against gravity) and/or kinetic (occurring during voluntary movement). It usually resolves when the body part relaxes. Other characteristics of essential tremor include the following:

Both upper extremities are typically affected
Mild asymmetry is not uncommon
Tremor also may affect the head, voice, and lips
Tone and reflexes are normal
Parkinsonian features such as rigidity, are absent

There are data calling into question the tenet that essential tremor is truly monosymptomatic. Findings associated with essential tremor include changes in cognition, personality,^[39]mood,^[40]hearing,^{[41, 42]}and motor symptoms associated with cerebellar outflow.^[43]

Differential Diagnoses

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Author

Natalya V Shneyder, MD Assistant Professor, Department of Neurology, Movement Disorders Center, University of South Florida Morsani College of Medicine; Attending Physician, Movement Disorders Specialist, Department of Neurology, James A Haley Veterans Hospital

Natalya V Shneyder, MD is a member of the following medical societies: American Academy of Neurology, Movement Disorder Society

Disclosure: Nothing to disclose.

Coauthor(s)

Robert A Hauser, MD, MBA Professor of Neurology, Molecular Pharmacology and Physiology, Director, USF Parkinson's Disease and Movement Disorders Center, National Parkinson Foundation Center of Excellence, Byrd Institute, Clinical Chair, Signature Interdisciplinary Program in Neuroscience, University of South Florida College of Medicine

Robert A Hauser, MD, MBA is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Society of Neuroimaging, International Parkinson and Movement Disorder Society

Disclosure: Received consulting fee from Cerecor for consulting; Received consulting fee from L&M Healthcare for consulting; Received consulting fee from Cleveland Clinic for consulting; Received consulting fee from Heptares for consulting; Received consulting fee from Gerrson Lehrman Group for consulting; Received consulting fee from Indus for consulting; Received consulting fee from University of Houston for consulting; Received consulting fee from AbbVie for consulting; Received consulting fee from Adama.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida Morsani College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, American Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Bioserenity, Ceribell, Eisai, Jazz, LivaNova, Neurelis, Neuropace, SK life science, Sunovion, Takeda, UCB<br/>Serve(d) as a speaker or a member of a speakers bureau for: Aquestive, Bioserenity, Eisai, Jazz, LivaNova, Neurelis, SK life science, Stratus, Sunovion, UCB<br/>Received research grant from: Cerevel Therapeutics, Ovid Therapeutics, Neuropace, Greenwich Jazz, SK Life Science, Xenon Pharmaceuticals, UCB, Marinus, Neuroelectrics Corporation, Longboard, Janssen, Equilibre Biopharmaceuticals.

Additional Contributors

Deborah A Burke, MD Clinician, Sub-Investigator, USF Parkinson's Disease and Movement Disorders Center, University of South Florida Morsani College of Medicine; Investigator, Physician, Roskamp Institute Memory Clinic

Deborah A Burke, MD is a member of the following medical societies: American Academy of Neurology, International Parkinson and Movement Disorder Society

Disclosure: Nothing to disclose.

Theresa A McClain, RN, MSN, ARNP-BC Advanced Registered Nurse Practitioner and Investigator, Parkinson’s Disease and Movement Disorders Center, University of South Florida College of Medicine

Theresa A McClain, RN, MSN, ARNP-BC is a member of the following medical societies: Sigma Theta Tau International

Disclosure: Received consulting fee from Teva for consulting; Received consulting fee from Schering Plough for consulting; Received consulting fee from Biotie for consulting; Received consulting fee from Novartis for consulting.

Acknowledgements

Nestor Galvez-Jimenez, MD, MSc, MHA Chairman, Department of Neurology, Program Director, Movement Disorders, Department of Neurology, Division of Medicine, Cleveland Clinic Florida

Nestor Galvez-Jimenez, MD, MSc, MHA is a member of the following medical societies: American Academy of Neurology, American College of Physicians, and Movement Disorders Society

Disclosure: Nothing to disclose.

Daniel H Jacobs MD, FAAN, Associate Professor of Neurology, University of Florida College of Medicine; Director for Stroke Services, Orlando Regional Medical Center

Daniel H Jacobs is a member of the following medical societies: American Academy of Neurology, American Society of Neurorehabilitation, and Society for Neuroscience

Disclosure: Teva Pharmaceutical Grant/research funds Consulting; Biogen Idex Grant/research funds Independent contractor; Serono EMD Royalty Speaking and teaching; Pfizer Royalty Speaking and teaching; Berlex Royalty Speaking and teaching

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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