Synopsis
Diagnose the bilateral action-tremor syndrome positively, exclude reversible and dystonic or parkinsonian mimics and match functional treatment to comorbidity, task and patient goals.
- Essential tremor is an isolated action-tremor syndrome, usually bilateral in the upper limbs, persistent for at least several years and without parkinsonism, cerebellar ataxia or another explanatory neurological sign.
- Postural and kinetic components affect writing, pouring, cutlery, cups, tools or presentation tasks; head or voice tremor may occur but isolated head tremor needs careful dystonia review.
- The tremor is often asymmetric in amplitude despite bilateral involvement and may worsen with anxiety, fatigue, caffeine, adrenergic medicines and precise goal-directed movement.
Key red flags
A fine fast symmetrical tremor arises with adrenergic symptoms, fever, anxiety, thyrotoxicosis, excess caffeine, beta-agonists or alcohol withdrawal and improves when the trigger resolves.
Investigation priorities
Classify rest, postural, kinetic, intention and task-specific components and identify associated neurological signs.
Management branches
A patient presents with persistent shaking during posture or purposeful movement.
- Define onset, progression, distribution, activation, task specificity, family history and functional burden, and ask about medicines, caffeine, anxiety, alcohol pattern and withdrawal.
- Demonstrate bilateral action tremor and actively look for bradykinesia, rigidity, dystonia, cerebellar, neuropathic and functional signs; use targeted bloods or imaging only for a clue-led differential.
Key medicines
PropranololA common adult start is 40 mg two or three times daily, titrated by response.
PrimidoneStart very low, often 25 mg at night, and increase gradually under local guidance.