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.
- A family history is common but not required. Temporary improvement with alcohol is neither specific nor a safe diagnostic or therapeutic strategy.
- Look for rest tremor with bradykinesia and rigidity, cerebellar dysmetria, dystonic posturing or a null point, neuropathy, functional variability and enhanced physiological causes before using the essential label.
- Review medicines and substances including beta-agonists, valproate, lithium, antidepressants, stimulants, tacrolimus, caffeine and alcohol or benzodiazepine withdrawal.
- Thyroid function and other tests are driven by the history; routine brain imaging is not required for a classic stable isolated action tremor.
- Treat only when the tremor causes disability, distress or important occupational risk. Propranolol and primidone are common first-line oral choices, selected around comorbidity and preference.
- Botulinum toxin can help selected refractory limb, head or voice tremor, while deep-brain stimulation or unilateral focused ultrasound is reserved for severe medication-resistant disability after expert selection.
- Occupational adaptation, weighted or stabilising strategies, accessible technology and realistic task-specific goals can offer as much value as a small reduction on a tremor scale.
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.
- When an isolated longstanding action syndrome remains, explain essential tremor and its uncertainty, document baseline tasks and safety-net new rest, gait, cognitive or focal features.
Key medicines
PropranololA common adult start is 40 mg two or three times daily, titrated by response.Avoid in asthma, significant bradycardia, heart block or decompensated heart failure; monitor pressure, pulse, fatigue and masking of hypoglycaemia, and do not stop high regular doses abruptly.
PrimidoneStart very low, often 25 mg at night, and increase gradually under local guidance.The first doses can cause marked sedation, nausea, dizziness and ataxia; review falls, driving, blood count where indicated, interactions and pregnancy considerations.