You may be surprised to learn that everyone has some degree of tremor—an involuntary, rhythmic shaking, especially of the hands. For most of us, though, the movements are so small they can’t be seen or felt.
Many people, however, develop a visible tremor, which can trigger fears of Parkinson’s disease or some other neurological disorder. But in most cases the problem is essential tremor—a common movement disorder. Although essential tremor isn’t life threatening, and its symptoms can be mild, a severe tremor can have a significant impact on your quality of life.
The first sign of essential tremor is an up-and-down rapid shaking of the hands, but it can also affect the head, the voice, the arms or, more rarely, the legs. It often first appears in midlife and gradually worsens with age; most patients are over 65.
Essential tremor is known as an “action tremor,” which means that it usually occurs while the affected body part is in motion. By contrast, tremor in Parkinson’s disease typically occurs at rest, and it’s usually accompanied by additional symptoms.
Signs of essential tremor include:
• Rapid or moderate shaking of the hands and fingers and, less frequently, the head, tongue, voice or other parts of the body
• Worsening of the tremor when under emotional or physical stress; when voluntarily moving the hands, head and certain muscles; when trying to hold the head or hands still
• Cessation of the tremor when at rest
• Shaky handwriting
• Quavering voice
The exact cause still eludes doctors, but there’s a clear hereditary component; more than half of all cases occur in people who have a close relative with a tremor. For most people, essential tremor is distressing but not debilitating. For those with more severe symptoms, the tremor can hinder their ability to perform tasks like writing, dressing or drinking. Tremor can also be a source of embarrassment, leading to social withdrawal.
Fortunately, a range of treatment options can provide relief.
Pinning down a diagnosis
Essential tremor is frequently misdiagnosed and is often confused with Parkinson’s disease. As with Parkinson’s, in other diseases, including thyroid disorders and, rarely, brain tumors, tremor can be one of multiple medical signs and symptoms of the underlying condition. Your primary care provider must perform a medical evaluation and sometimes order blood tests and selective brain imaging before he or she can diagnose essential tremor.
Tremor can be a side effect of certain medications like thyroid or asthma drugs. Your provider should carefully review your prescription and over-the-counter drugs and nutritional supplements before recommending appropriate therapy.
There are several approaches to coping with essential tremor before trying medication. Here are some to try:
• Cut back on coffee, tea, and other caffeinated beverages, such as colas.
• If you smoke, quit, because nicotine aggravates tremors.
• Some patients find relaxation techniques and support groups helpful, as stress, anxiety, and fatigue may intensify tremors.
• Adaptive devices can be useful for accomplishing daily tasks. These devices include wrist weights to promote hand stability, weighted utensils, and plate guards to keep food from being pushed off the plate.
• Alcohol in small quantities can temporarily improve essential tremor in some people. But alcohol should be used judiciously, especially since its adverse effects are often greater than its benefits to reduce tremor.
A rebound effect can cause the tremor to worsen when the alcohol wears off. It can also lead to alcohol abuse or dependence. In fact, heavy alcohol use has been shown to lead to essential tremor.
The American Academy of Neurology (AAN) updated its guidelines in 2011 for treating essential tremor.
They recommended the following interventions if nonmedical approaches fail to bring improvement. But, for most adults who experience tremor, the adverse effects of medication are greater than the benefits of reducing tremor.
The AAN concluded that two drugs are equally effective at reducing tremors and either one could be used when tremor is severe enough to consider drug therapy:
• Propranolol (Inderal, InnoPran XL), a beta-blocker commonly prescribed for high blood pressure, is effective against limb tremors and may reduce head tremors as well.
You can take propranolol as needed, but daily use may be more effective. One dose lasts about four to six hours, enough to help you through a social engagement. Propranolol has a number of side effects, such as light-headedness, fatigue, depression, bradycardia (a slow heartbeat), and sexual dysfunction. People with asthma and certain heart conditions shouldn’t take propranolol. People with diabetes can take propranolol but with caution because beta-blockers can mask the symptoms of hypoglycemia.
• Primidone (Mysoline), an anticonvulsant typically used to treat seizures, is effective in reducing limb tremor and is associated with few long-term side effects. Primidone may initially cause nausea, vomiting, fatigue, confusion, poor coordination and unsteadiness, but these side effects disappear within a few days. Unlike propranolol, primidone must be taken daily.
Both drugs are sometimes combined, but for older adults who take multiple medications, the benefits are likely smaller than the adverse experiences associated with the combination.
The degree of relief provided by propranolol and primidone varies: Thirty to 50 percent of patients don’t see an improvement or can’t tolerate either drug. In these cases, doctors may prescribe other beta-blockers or anticonvulsants that can help.
Although some doctors consider the anti-anxiety drug alprazolam (Xanax, Niravam) as a second-line option, the potential adverse effects of confusion, falls, and addiction are significant reasons to avoid this medicine, even though the U.S. Food and Drug Administration lists alprazolam as “probably effective” in treating essential tremor.
Botox injections in the hand can provide modest improvement for some people, but the injections can cause significant hand weakness and don’t provide clear functional benefits.
For severe tremors that don’t respond to other treatments, the AAN recommends two procedures that can provide long-term, and sometimes permanent, improvement for most patients, but they both require brain surgery:
• Deep brain stimulation. Neurosurgeons implant a stimulation device, similar to a cardiac pacemaker, in the brain. The device is programmed to disrupt communication between nerve cells that produce tremors. The device can be reprogrammed for optimal benefit as needed.
• Unilateral thalamotomy. Neurosurgeons drill a hole in the skull to create a lesion in the area of the brain that controls movement to destroy the tremor-causing brain cells, thereby suppressing tremors.
Both deep brain stimulation and unilateral thalamotomy can cause side effects such as difficulty speaking, visual disturbances, and loss of balance or coordination, but deep brain stimulation is considered safer and has fewer complications.