Approach Considerations

No biologic markers exist for essential tremor. If the family history and examination findings are indicative of essential tremor, no laboratory or imaging studies are required. However, if the family history and examination findings are not indicative of essential tremor, laboratory and imaging studies should be considered.^{[44, 45]}

Laboratory investigations may include the following:

Standard electrolyte panel
Thyroid function tests
Blood urea nitrogen (BUN)
Creatinine
Liver function tests
Serum ceruloplasmin (for Wilson disease)

Procedures

Electromyography or accelerometry can be used to assess tremor frequency, rhythmicity, and amplitude but is not part of the routine evaluation.

Imaging Studies

Findings on computed tomography (CT) scanning and magnetic resonance imaging (MRI) of the head are normal in essential tremor. MRI helps to exclude structural and inflammatory lesions (including multiple sclerosis) and Wilson disease. MRI should be performed if the tremor has acute onset or stepwise progression.

Although the classic resting tremor of Parkinson disease is different in many aspects from essential tremor, Parkinson’s disease often does cause postural and action tremors in addition to resting tremors and may be difficult to distinguish from essential tremor if other signs are absent or minimal. Single-photon emission CT (SPECT) scanning using ioflupain 123 I (DaTSCAN) is a US Food and Drug Administration (FDA)–approved procedure that can help determine whether there is loss of dopamine neurons as occurs in Parkinsons disease and related disorders (and not in essential tremor), thus helping to distinguish these conditions.^{[5, 6, 7, 46]}

Midbrain ultrasonography has been suggested as a tool to differentiate essential tremor from Parkinson’s disease as a result of a study finding that high substantia nigra hyperechogenicity has a high positive predictive value for Parkinson disease. Another study found a significant increase in substantia nigra hyperechogenicity in patients with essential tremor compared with controls.^{[47, 48, 49, 50]}

Other Tests

In 2017, researchers described an electrophysiological measure that can discriminate Parkinson's disease tremor and essential tremor with high diagnostic accuracy. The tremor stability index, derived from kinematic measurements of tremulous activity, was tested in a cohort comprising 16 rest tremor recordings in tremor-dominant Parkinson's disease and 20 postural tremor recordings in essential tremor, and validated on a second, independent cohort comprising a further 55 tremulous Parkinson's disease and essential tremor recordings. The index's maximum sensitivity, specificity and accuracy were 95%, 95% and 92%, respectively.^[51]

Treatment & Management

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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