Tremor, Essential

Tremor may begin at any age

Cause is uncertain

Sometimes inherited in an autosomal dominant manner

Tremor is enhanced by emotional stress

Postural tremor usually involves one or both hands, the head, or the hands and head, whereas the legs tend to be spared

Speech may also be affected if the laryngeal muscles are involved

Physical examination reveals no other abnormalities

Ingestion of a small quantity of alcohol commonly provides remarkable but short-lived relief by an unknown mechanism

Typically becomes more conspicuous with time

Occasionally, it interferes with manual skills and leads to impairment of handwriting

Propranolol long-acting, either intermittently or indefinitely, 60–240 mg once daily orally

Primidone may be helpful, but patients are often very sensitive to it

• Starting dose is 50 mg once daily orally

• Daily dose is increased by 50 mg every 2 weeks depending on the response

• Maintenance dose of 125 mg three times daily orally is commonly effective

Occasional patients do not respond to these measures but are helped by

• Alprazolam (up to 3 mg daily orally in divided doses)

• Topiramate (up to 400 mg daily orally, titrated up over 6–8 weeks)

• Gabapentin (1800 mg daily orally in divided doses)

Botulinum toxin A

• May reduce tremor

• Adverse effects include dose-dependent weakness of the injected muscles

Disabling tremor unresponsive to medical treatment may be helped by high-frequency thalamic stimulation ("deep brain stimulation") on one or both sides, according to laterality of symptoms

Focused transcranial ultrasound thalamotomy using MRI guidance is also effective as is stereotactic radiosurgery for unilateral upper extremity tremor