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Essential tremor and how to tell it from parkinsonian tremor
Essential tremor is an action and postural tremor, bilateral and symmetrical in the hands, sometimes in the head and voice, with a family history and improvement after alcohol; parkinsonian tremor is an asymmetric rest tremor that disappears with movement and comes with slowness.
Why it matters in the exam
A recurring exam question is "what supports a diagnosis of essential tremor?" — the correct answers: a family history, improvement with alcohol, tremor on posture and action. Other questions describe an older adult whose tremor interferes with function and ask about treatment, or a patient taking a drug that causes tremor.
Before the diagnosis, exclude enhanced physiological tremor: hyperthyroidism, caffeine, anxiety and drugs (lithium, valproate, bronchodilators, SSRIs, amiodarone).
Essential tremor is the most common movement disorder in adults, and many patients fear it is Parkinson's disease. A simple clinic examination — arms held outstretched, drinking from a cup, writing or drawing a spiral, then sitting with the hands on the knees — separates action tremor from rest tremor in most cases, and allows the doctor to reassure or refer to a neurologist.
Further questions deal with treatment: propranolol and primidone are first line, and severe cases are referred for deep brain stimulation. Before treatment check for asthma, a slow pulse or insulin-treated diabetes, because a beta-blocker does not suit them. Another question describes a patient taking lithium, valproate or a bronchodilator who shakes — here the answer is reviewing the drug, not diagnosing essential tremor. In an older person with a new tremor, ask about caffeine and anxiety too.
Key points
- Essential tremor — action and posture, bilateral, familial, improves with alcohol.
- Parkinsonian tremor — rest, asymmetric, with slowness.
- Exclude: thyroid, caffeine, anxiety, drugs.
- Treatment: propranolol or primidone.
- Severe cases — deep brain stimulation.
Summary table
| Tremor type | When it appears | Features | Treatment |
|---|---|---|---|
| Essential tremor | On posture and action (a cup, writing) | Bilateral, symmetrical; head and voice; family history; improves with alcohol | Propranolol or primidone; deep brain stimulation in severe cases |
| Parkinsonian tremor | At rest | Asymmetric, "pill-rolling", disappears with movement; slowness and rigidity | Levodopa and dopaminergic drugs |
| Enhanced physiological tremor | On posture | Fine and fast; caffeine, anxiety, hyperthyroidism, drugs | Treat the cause |
| Cerebellar (intention) tremor | On approaching a target | Worsens towards the target; unsteadiness | According to the cause (stroke, multiple sclerosis, alcohol) |
| Drug-induced parkinsonism | At rest | More symmetrical; antipsychotics, metoclopramide | Stop the drug |
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Sources
- International Parkinson and Movement Disorder Society, 2018 — Consensus statement on the classification of tremors
- American Academy of Neurology, 2011 (reaffirmed) — Evidence-based guideline update: treatment of essential tremor
- Goroll AH, Mulley AG. Primary Care Medicine, 8th edition (2020) — Evaluation of tremor
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.