History and exam

Key diagnostic factors

common

presence of risk factors

Key risk factors include advanced age, familial history, white ancestry, and exposure to environmental toxins.

postural and/or kinetic tremor

A bilateral upper limb action tremor, with absence of other neurological signs, such as dystonia, ataxia, or parkinsonism is the core sign of essential tremor.[5]

problems with fine motor tasks

Patients often report a long history of progressive functional decline in activities that require use of their upper extremities due to tremor. Activities of daily living such as writing, eating, drinking, and dressing are typically impacted. The use of straws and of cups with lids, and delegating responsibilities to a spouse or carer, are common historical presentations.

Other diagnostic factors

common

abatement of tremor after consumption of alcohol, benzodiazepines, barbiturates, or gabapentin

Essential tremor is suppressed by multiple medicines that affect gamma-aminobutyric acid (GABA)-ergic systems, including alcohol, benzodiazepines, barbiturates, and gabapentin.[57]

head or voice tremor

Patients may present with or without tremor in other locations (e.g., head, voice, or limbs).[5]

uncommon

resting tremor

Resting tremor may occur in advanced essential tremor (ET), but resting tremor does not subside during voluntary movements in ET and possibly also not in dystonic tremor.[5]

Risk factors

strong

advanced age

The prevalence and incidence of essential tremor increases with age.[13] More than 50% of cases are >70 years of age.[6]

family history

Essential tremor (ET) has long been known to run in families.[68][69] However, the genetic basis appears to be heterogeneous, as linkage analysis is not consistently demonstrated, and a positive family history has been estimated to exist in 17% to 100% of patients.[25][70] Accordingly, absence of ET family history by no means precludes its diagnosis, and rather than being due to a single gene, the condition may be polygenic.

weak

white ancestry

Two studies have shown a greater prevalence of essential tremor (ET) in white Americans than in those with black ancestry, and a third study reported a higher likelihood of Americans with white ancestry having physician-diagnosed ET than those with black ancestry.[17][18][19]

exposure to environmental toxins

While they have not been systematically investigated, the following environmental toxins have been suggested as risk factors: organochlorine pesticides, lead, mercury, and beta-carboline alkaloids (e.g., harmane or harmaline, which are found in several medicinal plants).[30] In particular, harmane has been found to be elevated in the blood and brain of patients with essential tremor.[31][32][33]

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