Essential tremor

Essential tremor


Essential tremor is a type of uncontrollable shake or tremble of part of the body.

Most people with essential tremor experience a trembling, up-and-down movement of the hands.

The arms, head, eyelids, lips and other muscles can also be affected. A tremor in the voice box (larynx) may cause a shaky voice.

Essential tremor is usually more noticeable when you’re trying to hold a position or do something with your hands, such as write. It doesn’t always affect both sides of the body equally.

Essential tremor is a common movement disorder affecting around four out of 100 adults over 40 years of age. Some people only have a mild tremor at first, which usually gets more severe over time.

‘Normal’ tremor

Everyone has a very minor tremor when carrying out daily activities. For example, your hands will shake slightly when you hold them out in front of you. This is normal.

Sometimes, the everyday level of tremor can become more noticeable, particularly in older people. Noticeable tremor is also normal and it’s often caused by a raised level of adrenaline in the body, which can happen when a person is stressed, anxious or angry.

When does a tremor become a problem?

Essential tremor is more severe than normal tremor and it gradually gets worse over time. Eventually, the tremor may become so severe that carrying out normal, everyday activities can become difficult.

Certain things may temporarily increase any tremor, including:

  • tiredness caused by strenuous activity or lack of sleep
  • smoking
  • caffeine – from tea, coffee and some fizzy drinks
  • being very hot or cold
  • taking certain medicines including some antidepressants and treatments for asthma

When to see your GP

It’s important to visit your GP if you experience frequent or severe tremors.

Although there’s no specific test to diagnose essential tremor, your GP can carry out a physical examination and may request further tests to rule out other conditions (see causes, below).

They’ll also ask about your personal and family medical history as part of their assessment.

Treating essential tremor

There’s no cure for essential tremor, but medicines can be used to help improve the symptoms in at least half of people with the condition.

In rare cases, a severe tremor may be treated with surgery if it doesn’t respond to medication.

Read more about treating essential tremor.

Inherited essential tremor

Essential tremor can run in families and research suggests it’s passed on by a faulty gene. At least half of people with the condition have a family member who also has it. 

However, the age at which a tremor develops and its severity can vary greatly between different family members. Some people may also develop the faulty gene without inheriting it from either parent.

Other causes of tremor

There are a number of conditions which may cause tremor, including:

  • overactive thyroid (hyperthyroidism)
  • Parkinson’s disease, a long-term condition affecting the way the brain co-ordinates body movements
  • multiple sclerosis, a condition of the central nervous system (brain and spinal cord) affecting the senses and the body’s actions
  • dystonia, a range of movement disorders which cause involuntary muscle spasms
  • stroke, which very rarely may result in tremor with few other symptoms
  • peripheral neuropathy, where the peripheral nervous system is damaged

A tremor can also be one of the withdrawal symptoms for people who are dependant on alcohol and have stopped or reduced their alcohol intake.

Treating essential tremor

Treatment for essential tremor aims to reduce or remove the involuntary movements as much as possible.

If your tremor is mild and doesn’t stop you from carrying out normal activities, your condition may simply be monitored. Try to avoid things that may make your tremor worse, such as:

Speak to your GP if you’re taking medicine which could be causing a tremor. You should only stop taking prescribed medication if your doctor specifically advises you to.


If your tremor is more severe, your doctor may prescribe medication to reduce your symptoms. The most effective medicines are propranolol and primidone. Between half and three quarters of people find these medicines reduce their tremor.


Propranolol is a beta-blocker usually used to treat heart disease and high blood pressure (hypertension). It reduces tremors for a few hours after each dose. The possible side effects of taking propranolol include:

  • feeling sick
  • dizziness
  • cold extremities
  • impotence 
  • worsening of pre-existing asthma or heart failure


Primidone is an anticonvulsant, used to treat epilepsy, which also seems to help reduce essential tremor. Possible side effects include low blood pressure, drowsiness and feeling sick.

Another anticonvulsant, called topiramate, may also sometimes be used. If these medicines don’t work on their own, a combination of propranolol and an anticonvulsant may be recommended.


If combining the above medicines doesn’t work, there’s some evidence that sedatives such as clonazepam and alprazolam can help. These may improve your tremor because they reduce anxiety, which can often make the tremor worse. However, sedatives can cause drowsiness and there’s a risk you may become dependent on them.

Botulinum toxin

In rare cases, if the medicines described above prove to be ineffective, botulinum toxin may be used to treat essential tremor. The botulinum toxin is injected directly into the trembling muscles to block nerve transmissions and relax the muscles.

Botulinum toxin type A is a powerful poison that’s clinically safe when used in minute doses. It’s sometimes used to treat dystonic tremor rather than essential tremor. Dystonic tremor is a different type of tremor which causes involuntary muscle spasms and contractions (tightening).

Surgery for severe tremor

Sometimes the essential tremor may be so severe it significantly interferes with normal activity and doesn’t respond to medication. In these rare cases, surgery may be considered. There are two types of surgery:

  • deep brain stimulation
  • thalamotomy

These procedures are described below.

Deep brain stimulation

Deep brain stimulation involves placing one or more electrodes (small metallic needles) in an area of your brain called the thalamus. This is done under general anaesthetic, so you’re unconscious, though you are woken up during the procedure to make sure the electrodes are in the correct place.

Thin wires run from the electrodes to a pulse generator (a device similar to a pacemaker), which is implanted under the skin of your chest. The generator produces an electric current to help regulate your brainwaves and control your tremor.

The National Institute for Health and Care Excellence (NICE) published guidelines on deep brain stimulation for tremor in 2006. NICE concluded the treatment is effective in improving tremor, but more information is needed about how successful it is in the long-term. Other research has found deep brain stimulation can reduce tremor by around 90%.

Possible adverse effects of deep brain stimulation include:

  • infection of the surgical scar site
  • speech problems
  • tingling
  • bleeding in the brain
  • fluid in the brain
  • stroke, a serious medical condition caused by the blood supply to part of the brain being cut off
  • complications of general anaesthetic, such as nerve damage and numbness

Discuss these risks with your surgeon before deciding whether to have the procedure.

In the research NICE looked at, side effects were relatively rare. More recent research has also concluded that deep brain stimulation is a relatively safe procedure. Certain side effects can be eliminated by adjusting the level of stimulation produced by the pulse generator.


A thalamotomy involves making a small hole in the thalamus, which is the same area of the brain targeted for deep brain stimulation. The procedure has been shown to be effective in improving tremor.

Deep brain stimulation is often preferred to thalamotomy because it usually causes fewer side effects and some side effects can be reversed by adjusting the stimulation parameters or abandoning stimulation altogether.

However, thalamotomy has some advantages over deep brain stimulation, such as avoiding the need for follow up appointments to check the pulse generator and replace batteries.

Side effects of a thalamotomy can include:

  • confusion and problems thinking
  • speech and balance problems
  • bleeding in the brain
  • infection
  • paralysis

Getting help

If you’re affected by essential tremor, you can call the National Tremor Foundation (NTF) for help and support. Their telephone number is 01708 386399. You can also visit the NTF website for further information and advice.

Symptoms of essential tremor

Causes of essential tremor

Research suggests that essential tremor may be caused by a change (mutation) in one of your genes. Genes are inherited units of information (DNA) that determine how your body grows and functions.

It is thought that the gene mutation affects the areas of the brain known as the cerebellum and the inferior olive, altering the signals sent along the nerves to the muscles.

Inherited and non-inherited essential tremor

At least half of essential tremor cases are inherited. This means that a faulty gene is responsible for the condition and is passed on to you from your parents. Conditions that are passed on in this way are known as autosomal dominant disorders.

If one of your parents has a faulty gene for essential tremor, you have up to a 50% chance of developing the disorder yourself. However, how old a person is when they first develop the condition and its severity can vary greatly between different family members.

Unfortunately, there is no simple test to determine whether your essential tremor is caused by one particular faulty gene.

There may not always be a family history of essential tremor as not everyone with the mutated gene will develop symptoms. Similarly, some people may develop the mutation without inheriting it from either parent.

Tremor triggers

Your tremor may be triggered or made worse by one or more of the following actions:

  • making controlled or small, detailed movements, such as drinking a glass of water or writing
  • eating
  • putting on make-up
  • shaving

Being tired, anxious, hot or cold is also likely to make your symptoms worse.

Other causes tremor

There are a number of other conditions or factors that can cause a tremor. These include:

  • overactive thyroid (hyperthyroidism)
  • Parkinson’s disease, a long-term condition that affects the way the brain co-ordinates body movements
  • multiple sclerosis, a condition of the central nervous system (brain and spinal cord) that affects the senses and the body’s actions
  • dystonia, a range of movement disorders that cause involuntary muscle spasms
  • stroke, which very rarely may result in tremor with few other symptoms
  • peripheral neuropathy, where the peripheral nervous system is damaged
  • withdrawal symptoms when you stop drinking alcohol, which may affect people who were dependant on alcohol and have stopped or reduced their alcohol intake
  • amphetamines and other stimulants
  • medications, such as some antidepressants and some medicines that are taken for asthma
  • caffeine, in tea, coffee and some fizzy drinks