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Essential tremor: evidence-based advice

Evidence-based advice for conditions not covered by official guidelines

Evidence-based advice for conditions not covered by official guidelines

Objective

To differentiate essential tremor from Parkinson's disease and other diseases causing tremor.

Symptoms

• Tremor is initiated by movement (action tremor) and is rarely present at rest.

• It is most intense in a static sustained position, for instance extended arms.

• Tremor may be seen also in the tongue, and the head may be turned from side to side in a ‘no-no' movement, unlike Parkinson's disease.

• Psychological stress intensifies tremor, which can be heightened in social situations – for instance, when holding a cup of tea or coffee.

• Tremor is intensified when skilled acts need to be performed (such as a signature) and is relieved by ingesting small amounts of alcohol.

• Tremor can be quite incapacitating.

Diagnosis

• This is based on physical examination and patient history.

• Essential tremor is more common than tremor caused by Parkinson's disease, with a prevalence of about 5%.

• Roughly half of the patients are under 40 and for more than 60% there is a family history of the condition. Genetic defects have been located in at least two chromosomes (2p22 and 3q13).

• The pattern of inheritance is autosomal dominant – about half of the children may inherit the susceptibility for tremor.

Differential diagnosis

• There are none of the symptoms typical to Parkinson's disease, such as hypokinesia and rigidity.

• In essential tremor:

– the patient's face is expressive

– speed of movements is normal

– muscular tone is normal

– gait is normal.

• It may be more difficult to differentiate essential tremor clinically from enhanced physiological tremor in metabolic-toxic conditions.

• The risk of Parkinson's disease is higher in patients with essential tremor. Sometimes both types of tremor are concomitant.

Treatment

• Non-selective ß-blockers:

– propranolol 20-80mg two or three times a day

– timolol 10-15mg twice a day

• ß-blockers may be used as needed or regularly.

• Not all patients respond to medication.

• ß-blockers with intrinsic sympathomimetic activity (such as pindolol) aggravate the symptoms.

In selected cases, primidone or benzodiazepines can be given. Some patients benefit from acetazolamide, gabapentin or topiramate.

• Botulinum injections are used in some cases (tremor of the head, rarely hand).

• Neurosurgery (thalamic stimulation or thalamotomy) may be considered in drug-resistant and incapacitating cases. Thalamic stimulation is safer than thalamotomy and it may be inserted bilaterally.

This synopsis is taken from EBM Guidelines , a collection of treatment and diagnosis guidelines supported by evidence. © Duodecim Medical Publications. Distributed by Wiley-Blackwell. For more information, email freynold@wiley.co.uk or visit

Essential tremor Essential tremor

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