Tremor

Disease Description (Causes and Symptoms)

• Definition: Tremor is a symptom in which part of the body shakes periodically. It may occur in the hands (hand tremor), head, neck, jaw, tongue, or voice.
• Main types: Essential tremor (ET, mainly action and postural tremor), Parkinson’s disease-related tremor (mainly resting tremor), and secondary tremor caused by medications, endocrine disorders, or metabolic conditions.
• Causes/pathophysiology: The exact cause of essential tremor is unknown, but abnormalities in the cerebellum (particularly Purkinje cells) and the thalamocortical oscillatory circuit are thought to be involved. It is often familial (hereditary). Medications (antipsychotics, antidepressants, etc.), hyperthyroidism, hypoglycemia, and excessive alcohol consumption may trigger or worsen it.
• Main symptoms: Hand tremor (especially severe when holding an object or maintaining a posture), head shaking, voice tremor, and temporary improvement with alcohol in some cases (essential tremor); Parkinson’s disease tremor tends to worsen at rest. Symptoms may interfere with daily activities (eating, writing, and social interactions).

Treatment Methods

• Medication treatment (general standard)
  • Beta-blockers: Propranolol (e.g., propranolol) — commonly a first-line choice for essential tremor. Use caution in cases of asthma, low blood pressure, or reduced heart rate.
  • Anticonvulsants: Primidone (primidone), topiramate (topiramate) — the efficacy and side effects (drowsiness, dizziness, cognitive decline) should be considered.
  • Other medications: Gabapentin (gabapentin), clonazepam (clonazepam), etc., may be used depending on the symptoms and the patient’s condition.
  • Local botulinum toxin injections: May be effective for specific areas, such as the neck (head shaking) and voice tremor.
• Procedures and surgery
  • Deep brain stimulation (DBS): Considered when symptoms cannot be controlled with medication and daily functioning is significantly impaired. Electrodes are inserted into the thalamus (mainly the VIM) or other areas to suppress tremor through electrical stimulation.
  • Focused ultrasound (high-intensity focused ultrasound thalamotomy, MRgFUS): Used in some patients as a noninvasive lesioning option.
  • Surgery-related complications (bleeding, infection, peripheral nerve/ cognitive/ language changes, etc.) should be explained in advance.
• Lifestyle management
  • Limiting caffeine, managing stress, and getting sufficient sleep are recommended. Alcohol may provide temporary improvement, but it is not recommended because of the risk of dependence and health problems.
  • Assistive devices (weighted cups, utensil grips, etc.), occupational therapy, and physical therapy can help support function.
• Precautions and risk of complications
  • Some medications may cause low blood pressure, reduced heart rate, drowsiness, or cognitive decline. Beta-blockers should be administered cautiously in patients with asthma, diabetes, or heart failure.
  • There is no medication that cures essential tremor — lifelong management is necessary. It may cause social and psychological impairment (anxiety and depression).
  • Surgery may improve symptoms, but surgical risks and long-term device-related problems exist.

Checklist Before an Outpatient Visit (Including Items to Bring and Example Questions)

• Items to bring (recommended)
  • A list of current medications, supplements, and herbal medicines (name, dosage, and administration time)
  • Past medical history, family history (tremor/neurological disorders), and recent test results (blood tests, imaging, etc.)
  • Records of when the tremor began and its course: age at onset, patterns of worsening, triggering factors (tension, posture, food, alcohol consumption, etc.), and relieving factors (alcohol, etc.)
  • Videos showing the tremor clearly (recorded on a mobile phone) — very useful for diagnosis
  • Information related to recent weight changes and whether thyroid disease or diabetes is present
• Information that is helpful to tell the doctor in advance during the outpatient visit
  • Specific effects of the symptoms on daily life (eating, writing, job performance, etc.)
  • The relationship with medications, alcohol consumption, and caffeine (whether symptoms improve or worsen)
• Example questions to check before the outpatient visit (patients should make their own notes)
  • When did the symptoms first begin, and how often do they occur?
  • What situations worsen or relieve them?
  • Does anyone in the family have similar symptoms?

Examples of General Questions to Ask the Doctor

• What are the expected effects and possible side effects of this medication (the recommended medication)?
• How much can the symptoms improve with medication treatment, and how long does it take for the effects to appear?
• Are there any lifestyle factors I should specifically avoid (caffeine, alcohol, etc.) and any recommended supportive exercises?
• If the symptoms cannot be controlled with medication, what are the indications and risks of surgical treatments (deep brain stimulation and focused ultrasound)?
• What is the long-term prognosis of this disease? Might social or psychological support be needed?

Examples of Disease-Specific Questions (1–2)

• Does my tremor appear to be essential tremor, or is it more likely to have another cause involving resting tremor, such as Parkinson’s disease? How can the causes be specifically differentiated?
• If the symptoms cannot be adequately controlled with medication, which treatment—deep brain stimulation (DBS) or focused ultrasound—is more suitable for my situation? What degree of improvement and risk of complications can be expected?