Essential Tremor Clinical Presentation

Updated: Oct 22, 2018
  • Author: Deborah A Burke, MD; Chief Editor: Selim R Benbadis, MD  more...
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Presentation

History

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

  • A family history of essential tremor is noted in 50-60% 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 several 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, hyperthyroidism, fever, and anxiety, should be excluded.

Like a previous population-based study from Spain, a community-based cohort study from New York by Thawani et al found an association between essential tremor and dementia. In cross-sectional analyses, dementia was present in 31 of 124 subjects with essential tremor versus 198 of 2,161 controls (25% vs 9.2%). In prospective analyses, dementia developed in 17 of 93 subjects with essential tremor versus 171 of 1,963 controls (18.3% vs 8.7%). [35]

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Physical Examination

Essential tremor generally 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 most patients with essential tremor do not have gait abnormalities.

The tremor is characteristically postural (occurring with voluntary maintenance of a position against gravity) and 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 bradykinesia and 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, [36] mood, [37] hearing, [38, 39] and motor symptoms associated with cerebellar outflow. [40]

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