FFinalistSouthampton · 2027
Neurology
AKT · Neurology/Movement & neurodegenerationlow yield

Essential tremor

Benign action/postural tremor (often autosomal dominant)

Overview

A common, often inherited, postural/action tremor of the hands (and sometimes head/voice) — the chief mimic of early Parkinson disease. The discriminators: it is symmetric, present on action (not at rest), and classically improves with alcohol.

Recognise

  • Symmetric postural/action tremor of the hands, worse with sustained posture or movement (e.g. holding a cup, finger-nose)
  • Often a head ("yes-yes"/"no-no") or voice tremor; autosomal dominant family history
  • Improves with alcohol and with rest; NO bradykinesia or rigidity

Red flags

  • Sudden onset, asymmetry, rest tremor or other neurology → reconsider Parkinson disease / secondary cause

Differentials & how to tell them apart

Parkinson diseaseasymmetric RESTING tremor + bradykinesia + rigidity, does NOT improve with alcohol
Physiological/enhanced tremorthyrotoxicosis, caffeine, salbutamol, anxiety — reversible cause
Cerebellar (intention) tremorworse approaching a target, with ataxia/past-pointing
Dystonic tremorwith abnormal posturing

Investigations

Clinical; consider TFTs (exclude thyrotoxicosis) and medication review (e.g. salbutamol). DaTscan only to separate from Parkinson disease if needed.

Management

Propranolol first-line (or primidone) if functionally impairing; reassure if mild

  1. 1Reassure if mild. If functionally/socially impairing → propranolol first-line (or primidone).Gate: Exclude reversible enhancers first (thyrotoxicosis, caffeine, salbutamol, anxiety) before labelling it essential tremor
  2. 2Refractory/severe → neurology; deep brain stimulation in selected cases.
Propranolol — first-line
Primidone — alternative

Key points

Symmetric + action + alcohol-responsive + no rigidity = essential tremor (vs Parkinson). Propranolol is the drug. Alcohol responsiveness is a classic clue.

Monitor & prognosis

Functional impact, treatment response.

Slowly progressive but benign; treatable symptomatically.

Source: NICE CKS Tremor