TremorBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f7200 (Published 12 December 2013) Cite this as: BMJ 2013;347:f7200
- Menelaos Pipis, foundation year 2 doctor1,
- Mohammad Dehabadi, foundation year 2 doctor2,
- Emma Matthews, specialist registrar in neurology3,
- Lawrence Gould, general practitioner4
- 1Accident and Emergency Department, Watford General Hospital, Watford WD18 0HB, UK
- 2Ophthalmology Department, Watford General Hospital
- 3Neurology Department, National Hospital for Neurology and Neurosurgery, London, UK
- 4The Stanmore Medical Centre, London, UK
- Correspondence to: M Pipis
- Accepted 12 September 2013
A middle aged man presents complaining of excessive shaking of his hand. Physical examination reveals bilateral hand tremor, right more so than the left, and worse when holding his arms outstretched. The remainder of the physical and neurological examinations are normal.
What you should cover
Tremor is the most common involuntary movement encountered in clinical practice. It is an unintentional, rhythmic muscle movement that usually affects the hands but can also affect the arms, head, legs, and rarely the trunk. Essential tremor is the commonest form, but tremor may sometimes be a symptom of an underlying neurological disorder or a manifestation of systemic disease, and patients are often worried about a diagnosis of Parkinson’s disease.
Ask the patient for a description of the “tremor” and how it has progressed over time:
- You may find that the patient is describing a tic—a sudden, repetitive, non-rhythmic movement often involving a single muscle group.
- A tremor that appears first in one hand and subsequently the other, perhaps spreading to one or both legs, is suggestive of Parkinson’s disease.
- A tremor that appears in both hands symmetrically, perhaps also involving a head tremor or a tremulous voice, is suggestive of essential tremor.
Under which circumstances does it occur?
- A tremor that occurs at rest and disappears or becomes less obvious with action is a resting tremor and is characteristic of the “pill rolling” tremor of Parkinson’s disease.
- A postural tremor occurs when a position is maintained against gravity, such as holding the arms outstretched, or carrying a cup. This is suggestive of essential tremor.
How long has the tremor been present, is it a constant problem, and how does it affect daily activities? These are important indicators of whether intervention is required.
Has it been getting worse? Essential tremor is usually mild and very slowly progressive.
Are there any exacerbating or relieving factors? Essential tremor is characteristically, although not exclusively, relieved by alcohol but can worsen with stress, anxiety, or heightened emotions.
Are there any associated features?
- Speech disturbances and changes in mobility or balance are features suggestive of Parkinson’s disease.
- Heat intolerance, palpitations, or weight loss are features suggestive of hyperthyroidism.
Is the patient taking β2 agonist inhalers? A tremor can occur in patients who have newly started using β2 agonists or in asthmatics with poor control who overuse their inhaler.
Is the patient taking lithium? A fine tremor is common with therapeutic levels of lithium, but a coarse tremor is a feature of toxicity—possibly precipitated by dehydration, diuretics, or angiotensin converting enzyme inhibitors.
Is the patient taking selective serotonin reuptake inhibitors or sodium valproate? Tremor can be a side effect of these commonly used drugs.
Has there been a change in dose of regularly used opiates or benzodiazepines? Tremor can be a feature of withdrawal.
Social history and lifestyle
Has the patient been drinking more caffeine-based drinks lately, as high doses of caffeine can cause tremor.
An accurate alcohol history should be elicited. Tremor can be a feature of withdrawal, but also patients that find alcohol alleviates their tremor may have taken to alcohol excess.
A family history of tremor is a strong indicator of essential tremor.
Ascertain the distribution and symmetry of the tremor and under which circumstances it occurs.
- A resting, asymmetrical, pill rolling tremor of the hands may point to Parkinson’s disease.
- A symmetrical tremor that is worse with outstretched hands—plus perhaps a head tremor or tremulous voice, or both—suggests essential tremor.
On neurological examination:
- Look for decreased facial expression, quiet voice, or a shuffling gait, and examine for rigidity and bradykinesia, as these are features suggestive of Parkinson’s disease.
- Look for dystonic posturing of the hands, such as hyperextension of the fingers when the hands are outstretched. If the tremor affects the head look for cervical dystonia, such as torticollis, which is often associated with muscle hypertrophy. The presence of tremor and dystonia affecting the same body part indicates a dystonic tremor.
On physical examination:
- Look for features of hyperthyroidism, such as a goitre, proptosis (“staring” appearance), or tachycardia.
- Look for signs of excess alcohol use, such as stigmata of chronic liver disease.
What you should do
In most instances, you will be able to reassure your patient about the benign nature of their tremor.
Routine blood tests—including thyroid function tests, liver function tests, and lithium levels if indicated—should be performed.
If the tremor is thought to be secondary to a drug then rationalisation of the medication list should be attempted. Where appropriate, optimisation of asthma control with preventers should be sought.
When essential tremor is suspected, a stepwise approach to management should be taken such as outlined in the box.
When to refer: When diagnosis is ambiguous, essential tremor refractory to treatment, suspected Parkinson’s disease, presence of focal neurology, or cervical dystonia since tremor associated with dystonia may respond to treatment with botulinum toxin in a specialist clinic.
Managing essential tremor
1) Lifestyle advice
Decrease intake of caffeine.
Patients that find alcohol to relieve their symptoms should be reminded of the risks of excessive alcohol use, and advised of the maximum recommended alcohol intake.
2) Medical management
Depending on the severity, frequency, and impact of the tremor on the patient’s life, decide with the patient whether medical management of the tremor is necessary; in some cases intermittent treatment may suffice, such as in high stress occasions.
Consider a trial of propranolol (starting at 40 mg two or three times a day). Advise the patient of its commonest side effects: dizziness, tiredness, and, rarely, erectile dysfunction. A slow release preparation can be used once a stable dose is achieved.
If propranolol is not tolerated or contraindicated then a trial of primidone (starting at 50 mg daily, up to a maximum of 750 mg daily). Common side effects are drowsiness, nausea, and rash.
If increasing doses of either drug does not control symptoms, a combination of both could be tried.
National Institute of Neurological Disorders and Stroke. Tremor fact sheet. 2012. www.ninds.nih.gov/disorders/tremor/detail_tremor.htm
General Practice Notebook. Tremor. www.gpnotebook.co.uk/simplepage.cfm?ID=899284992
Cite this as: BMJ 2013;347:f7200
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Not commissioned; externally peer reviewed.