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Essential Tremor Clinical
Presentation
Updated: Oct 22, 2018
Author: Deborah A Burke, MD; Chief Editor: Selim R Benbadis, MD  more...

PRESENTATION

History
The following characteristics can be noted in patients with essential tremor:

A family history of essential tremor is noted in 50-60% of cases

Tremor usually begins in one upper extremity and soon affects the other; essential tremor
rarely extends from the upper extremity to the ipsilateral leg

A mild degree of asymmetry is not unusual

In about 30% of cases, tremor involves the cranial musculature; the head is involved most
frequently, followed by voice, jaw, and face

Tremor may be intermittent initially, emerging only during periods of emotional activation

Over time the tremor becomes persistent

At any point in time, the frequency of the tremor is relatively fixed

The amplitude of the tremor is highly variable, depending on the state of emotional activation;
tremor amplitude is worsened by emotion, hunger, fatigue, and temperature extremes

The baseline tremor amplitude slowly increases over several years

A degree of voluntary control is typical, and the tremor may be suppressed by skilled manual
tasks

The tremor resolves during sleep

Ethanol intake temporarily reduces tremor amplitude in an estimated 50-70% of cases

Visible tremor is generally pathologic, but distinguishing between essential tremor and enhanced
physiologic tremor can be difficult. Causes of enhanced physiologic tremor, including medications,
stimulants such as caffeine, hyperthyroidism, fever, and anxiety, should be excluded.

Like a previous population-based study from Spain, a community-based cohort study from New
York by Thawani et al found an association between essential tremor and dementia. In cross-
sectional analyses, dementia was present in 31 of 124 subjects with essential tremor versus 198 of
2,161 controls (25% vs 9.2%). In prospective analyses, dementia developed in 17 of 93 subjects
with essential tremor versus 171 of 1,963 controls (18.3% vs 8.7%).
[35]
Physical Examination
Essential tremor generally is considered to be monosymptomatic (tremor only), although some
patients have abnormalities in gait and balance. If patients have such abnormalities, the diagnosis
should be carefully considered, because most patients with essential tremor do not have gait
abnormalities.

The tremor is characteristically postural (occurring with voluntary maintenance of a position against
gravity) and kinetic (occurring during voluntary movement). It usually resolves when the body part
relaxes. Other characteristics of essential tremor include the following:

Both upper extremities are typically affected

Mild asymmetry is not uncommon

Tremor also may affect the head, voice, and lips

Tone and reflexes are normal

Parkinsonian features such as bradykinesia and rigidity are absent

There are data calling into question the tenet that essential tremor is truly monosymptomatic.
Findings associated with essential tremor include changes in cognition, personality,
[36] mood,
[37]
hearing,
[38, 39] and motor symptoms associated with cerebellar outflow.
[40]

Differential Diagnoses
 
 

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