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A tremor is an involuntary repetitive movement of part of the body – most commonly the hands. Tremor is a common presenting complaint to general practice. Defining the features of the tremor can help to narrow down the diagnosis. In particular knowing if the tremor is worse at rest or during action, and if there are any other neurological features can help to make the diagnosis.

There are may possible cases of tremor including:

Differentiating type of tremor

  • Worse at rest
  • Reduced with intentional movements
  • “Pill rolling”
  • Initially unilateral, later becomes bilateral
  • Worse on intentional movements
  • Often reduced or absent at rest
  • Bilateral (may initially be unilateral
  • May involve head and vocal tremor
  • Never involves legs
  • Absent during sleep
  • Worse on intentional movements
  • “Past pointing”
  • Unilateral or bilateral
  • Tremor often irregular and jerky
  • Worse on intentional movements
Other features
  • “Mask-like” facial appearance
  • Low, quiet speech
  • Slowed gait – often has to ‘work-up’ to get moving
  • FHx of essential tremor
  • Commonly improves after drinking alcohol


  • Tone, power, reflexes and co-ordination in all 4l imbs
  • Cerebellar signs – nystagmus, ataxia, dysdiadochokinesia (inability to perform rapidly alternating movements)
  • Assessment of cognitive function – e.g. with MMSE or MoCA
  • Gait and posture
  • Lying and standing BP


  • FBC
  • U+E
  • TFTs
  • LFTs

Essential Tremor

  • The most common cause of tremor
  • Affects 50 per 1000 people over 60
  • Incidence increases with age
  • Can progress over time
  • May be confused with Parkinson’s disease in some patients
  • The typical tremor has a frequency of 4-12Hz
  • Neurological examination will usually be normal
  • Exclude another cause before starting treatment
  • Management
    • Reassure patients that it is not likely to be serious
    • Avoid: caffeine, stress, tiredness
    • Practical tips:
      • Use heavier utensils (yes really!)
      • Type instead of writing
      • Use wrist weights
      • Yoga or relaxation exercises
    • Propranolol 10mg PO BD. Dose can be increased slowly to a maximum of 160mg OD in 2-3 divided doses
    • Primidone 62.5mg PO nocte. Dose can be increased slowly up to a maximum of 250mg daily
      • Is just as effective as propranolol but more prone to side effects such as cause and fatigue
    • Some patients may require a combination of both drugs
    • If it is unresponsive to therapy – consider a specialist referral – deep brain stimulation and botox injections may be considered

Enhanced Physiological Tremor

  • May be normal
  • Ask about anxiety, fatigue
  • Check for endocrine causes – hyperthyroidism, Cushing disease, pheochromocytoma, hypoglycaemia
  • Drugs – salbutamol, caffeine, dopamine agonists, sodium valproate, tricyclic anti-depressants
  • Alcohol withdrawal


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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) FRACGP currently works as a GP and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University, and is studying for a Masters of Sports Medicine at the University of Queensland. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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