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Essential tremor — Clinical Guidelines

Overview

Essential tremor is a common movement disorder characterized by involuntary shaking, typically affecting posture and action but not at rest. It can involve various body parts, including the head and voice, and often has a familial component 1 11 16.

Diagnosis

Key Criteria: Tremor present during voluntary movement, absent or minimal at rest, rapid frequency (usually >4 Hz) 11 16.

Clinical Features: May involve voice and head, positive family history common 1 16.

Differential Diagnosis: Distinguish from Parkinson's disease (slower tremor, resting component) and dystonic tremor 4.

Recommended Tests: No specific diagnostic tests; clinical evaluation is primary 4.

Grading: Tremor severity can be assessed using clinical scales like the Tremor Rating Scale (TRS) 10.

Management

First-Line Treatments:

- Propranolol: Effective for many patients; typical dose range 20-30 mg tid 16 14. - Primidone: Often used as an alternative or adjunctive therapy 4.

Adjunctive Treatments:

- Botulinum Toxin: Beneficial for essential vocal tremor 3. - Thalamic Stimulation/Thalamotomy: Considered for severe, drug-resistant cases 6.

Non-Pharmacological:

- Speech Therapy: May help manage vocal tremor 3. - Alcohol: Transient beneficial effect noted, but not recommended due to risks 14.

Special Populations

Elderly: Commonly affected; management focuses on symptom relief and quality of life 1 10.

Comorbidities: No specific contraindications noted, but consider drug interactions and side effects 15.

Pregnancy: Limited data; cautious use of medications, focusing on safety and efficacy 15.

Key Recommendations

Use Propranolol as First-Line Medication for essential tremor management due to its efficacy and established use 16 (Evidence: Strong).

Consider Thalamic Stimulation for Severe, Drug-Resistant Cases as a viable surgical option 6 (Evidence: Moderate).

Evaluate and Manage Vocal Tremor with Speech Therapy and Botulinum Toxin Injections when pharmacological treatments are insufficient 3 (Evidence: Moderate).

Monitor for Alcohol Use in patients with essential tremor, noting prevalence similar to other neurologic disorders 15 (Evidence: Weak).

Differentiate Essential Tremor from Parkinson’s Disease based on tremor characteristics and presence of resting tremor 4 (Evidence: Strong).

References

1 Tsunoda K, Kobayashi R, Takazawa M, Morita Y. Kampo Medicine for Essential Voice Tremor. Alternative therapies in health and medicine 2021. link 2 Shill HA, Adler CH, Beach TG. Pathology in essential tremor. Parkinsonism & related disorders 2012. link70042-6) 3 Barkmeier-Kraemer J, Lato A, Wiley K. Development of a speech treatment program for a client with essential vocal tremor. Seminars in speech and language 2011. link 4 Evidente VG. Understanding essential tremor. Differential diagnosis and options for treatment. Postgraduate medicine 2000. link 5 Edwards R, Beuter A. Indexes for identification of abnormal tremor using computer tremor evaluation systems. IEEE transactions on bio-medical engineering 1999. link 6 Speelman JD, Schuurman PR, de Bie RM, Bosch DA. Thalamic surgery and tremor. Movement disorders : official journal of the Movement Disorder Society 1998. link 7 Humayun MU, Rader RS, Pieramici DJ, Awh CC, de Juan E. Quantitative measurement of the effects of caffeine and propranolol on surgeon hand tremor. Archives of ophthalmology (Chicago, Ill. : 1960) 1997. link 8 Hopfensperger K, Koller WC. Non-parkinsonian tremor. Current opinion in neurology and neurosurgery 1992. link 9 Gantert C, Honerkamp J, Timmer J. Analyzing the dynamics of hand tremor time series. Biological cybernetics 1992. link 10 Cleeves L, Findley LJ. Tremors. The Medical clinics of North America 1989. link30600-9) 11 Findley LJ. Essential tremor. British journal of hospital medicine 1986. link 12 Francolini P, Giaquinto S, Massi G, Nolfe G. Quantitative study of action tremor in various patient categories. Italian journal of neurological sciences 1985. link 13 Sabra AF, Hallett M. Action tremor with alternating activity in antagonist muscles. Neurology 1984. link 14 Koller WC, Biary N. Effect of alcohol on tremors: comparison with propranolol. Neurology 1984. link 15 Koller WC. Alcoholism in essential tremor. Neurology 1983. link 16 Paulson GW. Benign essential tremor: features that aid in diagnosis. Postgraduate medicine 1982. link 17 Oppel F, Umbach WU. A quantitative measurement of tremor. Electroencephalography and clinical neurophysiology 1977. link90012-8) 18 Calne DB, Webster RA. Tremor induced by tetrabenazine. British journal of pharmacology 1969. link

Essential tremor