Essential Tremor

History Taking

Chief Complaint:

• Intermittent shaking or tremors in hands and/or arms

• Difficulty in performing routine tasks requiring fine motor skills

• Involuntary rhythmic movements

History of Presenting Complaint:

• Onset, duration, and progression of the tremors

• Tremor worsens with voluntary movements or when reaching towards an object (action or intention tremor)

• Tremors may reduce or disappear during rest or sleep

• Possible presence of 'yes-yes' or 'no-no' head tremors (titubation)

• Difficulty with writing, eating, drinking or dressing due to tremors

• Presence of tremors in other body parts such as the legs, head, or voice (if voice is involved, patient might complain of changes in the quality of their voice or speech)

• No associated symptoms suggestive of Parkinson's disease like bradykinesia, rigidity, or postural instability

System Review:

• Neurological review should focus on excluding other potential causes of tremors (e.g., hyperthyroidism symptoms, alcohol withdrawal symptoms, use of certain medications)

Past Medical History:

• Any history of neurological conditions

• Other systemic illnesses like thyroid disease

• Previous diagnoses of tremors and their management

Drug History:

• Use of drugs known to cause tremors (such as amphetamines, corticosteroids, SSRIs, lithium)

• Regular alcohol use and potential withdrawal symptoms

• Response to any previously prescribed tremor medications

Family History:

• Essential tremor is often familial with autosomal dominant inheritance, so positive family history of tremors is relevant

Personal History:

• Smoking and alcohol consumption, as these can affect the nervous system and alcohol may temporarily relieve symptoms of essential tremor

• Exposure to toxins or occupational hazards known to affect the nervous system

Social History:

• Impact of the tremor on their occupation (if the job involves fine motor skills)

• Impact on their quality of life and activities of daily living

• Emotional distress, anxiety, or depression related to the condition

Physical Examination

General Examination:

• Patient may appear anxious due to the tremor

• Tremor may be observed when patient is at rest, but typically more noticeable with movement

Hands:

• Observable fine, rhythmic 'pill-rolling' tremor on outstretching hands

• Difficulty with tasks requiring precision such as buttoning a shirt or using a spoon, suggesting action tremor

• No evidence of muscle rigidity or bradykinesia

Arms:

• Postural tremor observed when arms are outstretched

• Kinetic tremor may be observed during finger-nose testing or drawing tasks

Face (Eyes, Nose, Mouth):

• Possible tremor in eyelids or other parts of the face

• 'Yes-yes' or 'no-no' head tremors may be observed (titubation)

• Tremors may affect jaw or lips, causing difficulty with speech

Neck:

• Observable tremor of neck muscles or head (in severe cases)

Neurological Examination:

• Normal muscle tone, power, and reflexes (to rule out other neurological conditions)

• Intention tremor could be confirmed using the finger-nose test or drawing a spiral

• Coordination and balance usually intact

• No evidence of rest tremor, rigidity or bradykinesia (helps differentiate from Parkinson's disease)

Investigations

Laboratory:

• Complete Blood Count: to rule out anemia or other hematological disorders

• Thyroid Function Tests: to exclude hyperthyroidism, which can cause tremors

• Liver Function Tests: to check for liver disease, especially in patients with a history of alcohol abuse

• Serum Electrolytes: to rule out electrolyte imbalances that could cause tremor

• Drug Levels: if the patient is on medications known to cause tremors (like lithium, amphetamines, or corticosteroids)

Imaging:

• MRI Brain: to rule out structural abnormalities causing tremor, such as stroke or brain tumor

Invasive:

• Lumbar Puncture: rarely necessary in cases of essential tremor, but can be useful if other neurological disorders are suspected

Other Tests:

• Electromyogram (EMG): may be useful in differentiating essential tremor from other forms of tremor

• Neuropsychological Tests: may be done to assess cognitive function, particularly if there are concerns about Parkinson's disease

• Trial of Propranolol or Primidone: a positive response can help to confirm the diagnosis of essential tremor.

Management

General Management:

• Patient education: Informing about the benign nature of the condition

• Lifestyle modifications: Reducing caffeine and alcohol intake

• Physiotherapy: May help to improve muscle control and coordination

• Occupational therapy: Adapting daily activities to minimize the impact of tremors

Medical:

• Beta-blockers: Propranolol is first-line treatment

• Antiepileptics: Primidone can be effective if beta-blockers are contraindicated or ineffective

• Benzodiazepines: Alprazolam can be used short-term for immediate relief

• Antidepressants: Mirtazapine can be considered in patients with co-existing depression

• Botulinum toxin injections: For severe hand or voice tremors not responsive to other treatments

Surgical:

• Deep Brain Stimulation: Electrodes are implanted in the brain to reduce symptoms, considered in severe cases not responsive to medication

• Focused ultrasound thalamotomy: A non-invasive procedure that uses focused ultrasound to target and ablate a part of the thalamus, used in medication-resistant cases

Other:

• Support groups: For psychological support and coping strategies

• Regular follow-up: To monitor the progression of the disease and the effectiveness of treatment