A coffee cup wobbles from hands shaking. A button refuses to cooperate. For millions of people, these small moments add up. And it has a name: essential tremor. This neurologic condition that causes rhythmic shaking—most often in the hands and arms—is not dangerous, but it can be deeply disruptive.
Essential tremor is often mistaken for Parkinson’s disease, but it is a distinct condition. In the past, involuntary shaking or tremors were sometimes seen as a natural part of aging, but that is no longer the case. The good news is that essential tremor is not something people need to simply live with but that can be managed.
The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.
In this installment, Efstathios Kondylis, MD, a neurosurgeon at Henry Ford Health in Detroit, took time to discuss what patients should know about essential tremor.
Henry Ford Health is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Essential tremor is a neurological disorder
“Essential tremor is a neurological disorder that causes tremor in patients,” said Dr. Kondylis. “It can be congenital. It can have a genetic component and can run in families.
“These tremors are often disabling. They can cause social anxieties, reluctance to go out and do normal activities that the rest of us take for granted,” he added. “Things like drinking coffee or eating can be challenging, and a lot of social stigma can come from tremors. It's a disease that's often treated medically, but there are also surgical and procedural treatment options that can be highly effective."
A tremor is involuntary movement
But what is a tremor? A tremor is an involuntary, rhythmic shaking or trembling of the body. When a person experiences a tremor, it most commonly affects their hands. It can also affect the arms, legs, head, vocal cords or torso. This often signals a neurological issue or other factors such as stress, fatigue, caffeine or medications. Tremors can make everyday tasks difficult but are usually not life-threatening.
While many people experience slight natural tremors, noticeable tremors can range from essential tremor to symptoms of disorders such as Parkinson’s disease.
It is different than Parkinson’s disease
Essential tremor and Parkinson’s disease “both belong to the broader category of movement disorders,” said Dr. Kondylis. “Essential tremor, by definition, includes tremor, and Parkinson’s disease is a related movement disorder that often includes tremors as one of its symptoms. But they’re very distinct diseases with different underlying causes.”
“The most important distinction is that essential tremor is really just a tremor,” he said. “Whereas Parkinson’s disease is a broader diagnosis that includes multiple symptoms such as hypokinetic movement, which is difficulty initiating movements, difficulty with creating facial expressions, freezing of gait and things of that nature, in addition to tremor.”
The cause of essential tremor is unknown
“There are some theories about the underlying changes in the dynamics of the brain,” said Dr. Kondylis. “But we don't necessarily have a single unifying understanding of how essential tremor comes about.”
However, in most people, the condition appears to be passed down from a parent to a child. For example, if your parent has essential tremor, there is a 50% chance you or your children will inherit the gene responsible for the condition.
Essential tremor develops earlier in life
“Essential tremor is often a disease that comes on earlier in life,” said Dr. Kondylis, noting that “people may notice it in their teens or their 20s and write it off as just something that they have to live with.”
Over time, essential tremor “can worsen, sometimes to the point where it becomes disabling. That's where it comes to my attention,” he said. “But there's not a cutoff, such as if you have this amount of tremor, then you have essential tremor.
“It's really when people come forward and start discussing their symptoms with their physicians,” Dr. Kondylis added. “I suspect that it affects more of us than we're willing to admit, and the real question is: Who does it affect enough that they seek treatment?”
Tremor of the hands is most common
“Essential tremor most often causes a tremor in the hands, though it can also cause tremors in other parts of the body—sometimes in the head or the legs,” Dr. Kondylis said. “But the most common symptom is a tremor of the hands.”
“People will often find that there are some things they can do to improve that tremor,” he said, noting “a very common one is drinking alcohol, which is interesting. Alcohol use is not an effective long-term treatment option, but tremor improvement with alcohol is actually one of the ways we can distinguish essential tremor from other things that can cause tremors.”
Essential tremor is diagnosed by a neurologist
Receiving a clinical diagnosis for essential tremor requires a patient to be evaluated by a neurologist, according to Dr. Kondylis.
“The biggest question is often essential tremor or Parkinson's. There are other things that can cause tremors, so you should visit a neurologist and be clinically evaluated. They may run some blood tests to rule out other less common causes of tremor,” he said. “Usually the question is whether your tremor is caused by Parkinson's or essential tremor. And both of those are clinical diagnoses.”
“If you're wondering which one you have, visit a neurologist and have them evaluate you,” said Dr. Kondylis. “They'll check for other symptoms that are common in Parkinson's disease. If they don't see those, the diagnosis is likely to be essential tremor.”
There is no cure for essential tremor
“There’s no cure for essential tremor, and not all patients seek treatment. For some people, the tremor is something they can live with. They may choose not to take medications or pursue other interventions,” Dr. Kondylis said.
He noted the first line of treatment is often medications such as propranolol, which blocks the stimulating action of neurotransmitters to calm your trembling, but can also cause side effects.
"They can affect blood pressure and various things and are sometimes not tolerated by patients. And sometimes they just don’t work very well,” he explained. “Once medications fail, the next line of treatment is deep brain stimulation surgery or an alternative treatment called high-intensity focused ultrasound.”
“Essentially, what those both come down to is either turning off or creating a lesion on the part of the brain that is in the tremor pathway, thereby reducing the tremor,” Dr. Kondylis said.
Avoid stressors that trigger tremors
For many, coping with their tremor means avoiding the stressors that trigger it in the first place.
“Some people find that situations that bring on social anxiety can bring out their tremor,” Dr. Kondylis said. “What I find very common is people will avoid situations where their tremor can cause social anxiety, so they may not go out to eat in public with you. Tasks like eating soup or drinking a glass of water in public can feel daunting for someone with a tremor.”
People with severe tremors in their hands may have difficulty with daily activities. Those with tremors in other parts of the body, such as the head or legs, can also experience challenges with walking or sleeping.
“But that's much rarer, and many of those people can benefit from medications or surgical treatments,” Dr. Kondylis said. “I suspect the majority of people who have essential tremor are walking around living their daily lives and finding ways to cope with the symptoms.”
Surgery for essential tremor is a big success
“Surgery for essential tremor is one of the big success stories of neurosurgery,” said Dr. Kondylis, noting that seeing the life-changing results of deep brain stimulation surgery is why many neurosurgeons enter the field.
“Many times, we perform that surgery with the patient awake, and they can literally watch their tremor disappear as we turn on the stimulator. It's very inspiring,” he explained. “Most people who are good candidates for deep brain stimulation can expect anywhere from 70% to 90% reduction in their tremor.”
High-intensity focused ultrasound offers new option
Recently, Henry Ford Health began offering an alternative treatment option for people with essential tremor called high-intensity focused ultrasound, or HIFU. The procedure is also approved by the Food and Drug Administration for treating tremor-dominant Parkinson's disease.
“It's an option for a lot of our patients who might not be candidates for deep brain stimulation," said Dr. Kondylis. “Deep brain stimulation involves making an incision in the skull, putting an electrode into the part of the brain contributing to the tremor and connecting that to a pacemaker-like device to stimulate that part of the brain—essentially 'turning off' that area so the tremor disappears.”
“The newer alternative is HIFU. This is an outpatient procedure performed without any incisions or anesthesia. Patients lie on the bed of an MRI machine while wearing a helmet-like device that has multiple sources of ultrasound energy. Where all those ultrasound waves converge, the tissue heats up, creating a small lesion in the brain,” he said. “So instead of 'turning off' that part of the brain, we create a lesion that permanently deletes the part of the brain causing the tremor.”
Barring major medical comorbidities, most essential tremor patients are candidates for the procedure. There is no upper age limit, and because the procedure does not require sedation, it can be a viable option for older patients who may not tolerate anesthesia well.
“The most important considerations for candidacy include the characteristics of the skull,” Dr. Kondylis said. “A CT scan can help us predict if a person's skull thickness may affect whether the sound energy can reach the targeted area of the brain."
“The other consideration is people have to lie flat in an MRI machine for about an hour or so. This may not be a great option for people who are claustrophobic or who have trouble lying flat,” he said.
Find other ways to cope with your tremor
“Most people living with essential tremor adapt to their tremor,” said Dr. Kondylis. “For example, they might get specialized utensils for eating or complete tasks with one hand supporting the other.”
“For many people, simple behavioral changes help them cope,” he said. “For those with more advanced tremors, it’s important to be open with your doctor. Take your medications as prescribed and share any side effects you experience, because while some people see tremor improvement, they also experience side effects they shouldn’t have to tolerate—and there are alternative medications."
"From there, the next step may be surgery or focused ultrasound, especially for people who have disabling tremor," Dr. Kondylis said.
Talk to your doctor about your tremors
“If your tremors are not affecting your life enough for you to consider medications or more advanced treatments, that's fine,” Dr. Kondylis said. “But it's definitely worth bringing up with your doctor so you can monitor it over time and notice any changes."
“If I were in my patients' shoes, I would probably start talking to a doctor when the tremor interfered with my activities of daily living,” he said. “And that depends a lot on what kind of work you do. If you're in a line of work that requires fine movements of the hands, then you may be reaching out to a doctor earlier than somebody else who doesn't require those same things.
“When it interferes with your daily life, that's a good time to talk to your doctor,” Dr. Kondylis added.
