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Essential Tremor
Aka: Essential Tremor, Benign Essential Tremor- Epidemiology
- Prevalence: 0.4 to 6%
- Most common pathologic Tremor cause in world
- Age of onset 20-60 years (bimodal distribution)
- Likely has onset for most patients in ages 20-30 years but is mild initially
- Later presentation at age 60-70 years coincides with the natural progression in severity
- Causes
- Genetic (Autosomal Dominant inheritance) in 50% of cases
- Sporadic
- Prevalence: 0.4 to 6%
- Symptoms and Signs
- Postural Tremor (Subset of Action Tremor)
- Initially presents as kinetic distal arm Tremor
- Some patients may have a postural component
- Usually bilateral (may be unilateral initially)
- Slowly progressive
- Rest Tremor is typically not present
- May progress to Rest Tremor if severe
- Frequency at 4-11 Hz
- Slower frequencies proximally
- Higher frequencies distally
- Distribution
- Provocative
- Not task specific
- Stress or Fatigue
- CNS Stimulant Medications
- Ask patient to hold hands out in front of them
- Ask patient to draw spiral
- Archimedes Spiral drawn (spiral with wavy hands)
- Palliative
- Small amounts of Alcohol
- Rest
- Postural Tremor (Subset of Action Tremor)
- Differential Diagnosis
- See Tremor
- See Postural Tremor
- Essential Tremor is a diagnosis of exclusion made on clinical grounds
- Parkinson's Disease
- Rest Tremor affecting extremities
- Labs: Not indicated unless atypical case
- Serum Chemistry Panel including Glucose
- Complete Blood Count
- Thyroid Stimulating Hormone (TSH)
- Management: General Measures
- Management: Medications - First line
- Effective in only 30-50% of Essential Tremor cases
- Beta Blocker (preferred)
- Most effective for limb Tremors, but will is also effective in head Tremor
- Non-selective Beta Blockers (preferred first-line)
- Propranolol
- Daily use: Propranol LA (Inderal) 80-320 mg daily
- Prn use: Propranolol 10-40 mg every 6 to 12 hours as needed
- Nadolol or Corgard (preferred Beta Blocker)
- Start: 40 mg once daily
- Maximum: 240 mg daily
- Propranolol
- Selective Beta Blockers (alternative in Obstructive Lung Disease)
- Anticonvulsant: Primidone
- Management: Specific Essential Tremor management (not responding to agents above)
- Refractory essential hand Tremor
- Topirimate starting with 25 mg daily
- Benzodiazepines prn
- Gabapentin (Neurontin) starting with 300 mg at night
- Refractory head and voice Essential Tremor
- Medications typically fail for control
- Head Tremor
- Botulinum Toxin Injection of cervical paraspinal and splenius muscle
- Voice Tremor
- Botulinum Toxin Injection of thyroarytenoid muscles (ENT and EMG guided)
- Severe Refractory Essential Tremor
- Medications are unlikely to be effective
- Bilateral Deep Brain Stimulation
- Primary Writing Tremor
- Medications tend to be ineffective
- Orthostatic Tremor (high frequency Tremor 13 to 18 Hz)
- Benzodiazepines may be effective
- References
- Ahiskog (2012) Mayo POIM Conference, Rochester
- Refractory essential hand Tremor
- Management: Medications - Other
- Other Agents
- Calcium Channel Blockers
- Carbonic Anhydrase Inhibitors
- Gabapentin (Neurontin)
- Topiramate
- Benzodiazepines
- Botulinum Toxin
- Experimental Agents
- Surgical management in very severe cases
- Other Agents
- Prognosis
- Indicators of better medication response
- Morbidity associated with impact on job functioning and social embarrassment, as well as Activities of Daily Living
- Up to 25% of patients change career or retire early due to Essential Tremor
- References