Bilateral, largely symmetric postural and kinetic tremor of the hands; the most common adult movement disorder.
Also known as: ET, benign essential tremor, familial tremor
Overview
An isolated tremor syndrome of bilateral upper-extremity action tremor of at least 3 years' duration, with or without tremor in other locations (head, voice, lower limbs), and absence of other neurologic signs such as dystonia, ataxia, or parkinsonism (per MDS 2018 consensus).
Epidemiology
Prevalence ~1% overall, rising to ~5% in adults over 65. Bimodal age distribution with peaks in the second and sixth decades. 50-70% have a positive family history (autosomal dominant pattern with variable penetrance).
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Question 1NeurologyMedium
A 70-year-old man reports a 5-year history of bilateral hand tremor that is present when he holds a cup or writes and is absent when his hands rest in his lap. The tremor improves after he drinks a glass of wine. Examination shows a symmetric tremor of both hands with the arms outstretched and during finger-to-nose testing, which he performs accurately. Tone, rapid alternating movements, gait, and the remainder of the neurologic examination are normal. Which of the following is the most likely diagnosis?
AEssential tremor
BDystonic tremor
CPhysiologic tremor
DParkinson disease
ECerebellar tremor
Reveal answer & full explanation
Correct answer: A — Essential tremor
AEssential tremor✓
BDystonic tremor
CPhysiologic tremor
DParkinson disease
ECerebellar tremor
Why Essential tremor is correct
Essential tremor is a bilateral action/postural tremor that appears with sustained posture and movement (holding a cup, writing) and is absent at rest.
Improvement after alcohol is a classic, highly suggestive feature of essential tremor.
Normal tone and rapid alternating movements exclude the rigidity and bradykinesia of a parkinsonian syndrome, and accurate finger-to-nose testing with a normal gait excludes the dysmetria and ataxia of a cerebellar process.
It is the most common movement disorder; first-line therapy is propranolol or primidone.
Why the others are wrong
Cerebellar tremor — an intention tremor that worsens on approaching a target and is accompanied by dysmetria and gait ataxia, neither of which is present; it does not improve with alcohol (buzzword-matching a movement-related tremor to an intention tremor)
Physiologic tremor — a fine, low-amplitude postural tremor that is normally invisible; the enhanced physiologic tremor becomes visible with a reversible trigger such as anxiety, caffeine, thyrotoxicosis, or a beta-agonist, and neither explains a 5-year bilateral tremor that improves with alcohol (premature closure on a "normal" finding)
Parkinson disease — produces a resting tremor with bradykinesia and rigidity, all absent here (anchoring on tremor in an older adult)
Dystonic tremor — a postural and action tremor of the hands that is often mistaken for essential tremor, but it arises in a body part affected by dystonia, is typically asymmetric and jerky, and may ease at a null point, whereas this man has a symmetric tremor on an otherwise normal examination without dystonic posturing (confused-with the other action tremor)
Question 2NeurologyMedium
A 68-year-old man reports a 5-year history of bilateral hand shaking that makes it hard to drink coffee, sign his name, and bring a spoon of soup to his mouth. He notes the tremor disappears when his hands rest in his lap and that a glass of wine briefly quiets it. His father had a similar tremor. On examination, a symmetric tremor appears when he holds his arms outstretched and during finger-to-nose testing, but there is no tremor at rest. There is no bradykinesia, rigidity, dystonic posturing, or limb ataxia. Which of the following is the most likely diagnosis?
AParkinson tremor
BPhysiologic tremor
CCerebellar tremor
DPsychogenic tremor
EEssential tremor
Reveal answer & full explanation
Correct answer: E — Essential tremor
AParkinson tremor
BPhysiologic tremor
CCerebellar tremor
DPsychogenic tremor
EEssential tremor✓
Why Essential tremor is correct
Classic picture: bilateral, symmetric action and postural tremor of the hands present for years, absent at rest, that interferes with writing, drinking, and feeding.
Supporting clues are a positive family history (autosomal dominant in 50-70%) and transient improvement with alcohol.
The absence of bradykinesia, rigidity, dystonia, and ataxia satisfies the MDS 2018 definition of an isolated action tremor syndrome.
Why the others are wrong
Psychogenic tremor — functional tremor begins abruptly, varies in frequency and amplitude, and shows distractibility or entrainment on examination; this man has a steady 5-year course with a reproducible postural and action tremor.
Physiologic tremor — the enhanced physiologic tremor is a fine, high-frequency postural tremor driven by a reversible trigger such as caffeine, anxiety, thyrotoxicosis, or a beta-agonist, and it neither runs in families nor progresses over years to disabling difficulty with writing and feeding.
Parkinson tremor — typically an asymmetric resting pill-rolling tremor that decreases with action and is accompanied by bradykinesia and rigidity; this patient's tremor is symmetric, action-predominant, and absent at rest.
Cerebellar tremor — the tremor on finger-to-nose testing suggests an intention tremor, but cerebellar tremor is a low-frequency intention tremor that worsens as the finger nears the target and comes with dysmetria and limb ataxia, typically from stroke, multiple sclerosis, or cerebellar degeneration; this man has a symmetric postural and action tremor without ataxia, plus a family history and alcohol response.
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Family history of tremor (autosomal dominant in many)
Advancing age
Possible environmental exposures (harmane in cooked meat, lead) — associations unproven
Pathophysiology
Pathogenesis incompletely understood but increasingly considered a network disorder centered on the cerebello-thalamo-cortical circuit. Pathologic studies show Purkinje cell loss and torpedoes in the cerebellum in many cases. Tremor frequency 4-12 Hz (typically 6-10 Hz).
Clinical presentation
Symptoms
Hand tremor with writing, drinking from a cup, eating soup, or holding a posture
Voice tremor produces a quavering quality, especially with sustained 'ahhh'
Head tremor (titubation), typically yes-yes or no-no
Often improves transiently with alcohol
Worsened by stress, fatigue, caffeine, sleep deprivation
Signs / physical exam
Postural tremor on outstretched arms
Kinetic tremor on finger-to-nose testing
No resting tremor (in pure ET)
No bradykinesia, rigidity, ataxia, or dystonia
Postural tremor appears immediately when the arms are outstretched; a postural tremor that re-emerges only after a latency of several seconds (re-emergent tremor) suggests Parkinson disease
Classic findings
Bilateral symmetric hand tremor present with action and posture, absent at rest, often with positive family history and alcohol responsiveness.
Differential diagnosis
Parkinson disease tremor — Asymmetric resting tremor, pill-rolling, accompanied by bradykinesia and rigidity; tremor decreases with action
MDS 2018: isolated tremor syndrome of bilateral upper limb action tremor for ≥3 years, ± other locations, without other neurologic signs.
Labs
TSH to exclude hyperthyroidism
BMP and glucose if metabolic causes suspected
Ceruloplasmin if age <40 to rule out Wilson disease
Medication review for tremorogenic drugs
Imaging
Brain imaging not routinely required — order MRI only if focal findings or atypical features
DaTscan SPECT can distinguish ET from PD when uncertain (normal in ET, abnormal in PD)
Treatment
First-line
Propranolol 60-320 mg/day (non-selective beta-blocker) — first-line, may need long-acting formulation; contraindicated in asthma, severe bradycardia, decompensated HF
Primidone 25-250 mg/day, titrated slowly — comparably effective to propranolol; common acute first-dose toxicity (sedation, ataxia, nausea) often abates
Combination of propranolol + primidone for refractory disease
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