Essential tremor

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 9 Jun 2025

Last updated: 08 Jul 2025

Essential tremor (ET) is characterised by a progressive tremor of the upper extremities, present in posture and action, without other neurological signs or symptoms.

The prevalence and incidence increases with age, but the condition can appear in early adulthood in those who have a family history.

Most people are only mildly affected. Those who seek medical care are disabled to some extent and often impaired socially by the tremor.

There is no cure, but there are treatments that provide relief and improve quality of life. These include drug therapies and surgical procedures.

Definition

Progressive, mainly symmetrical, rhythmic, involuntary oscillation movement disorder of the hands and forearms (69% of patients) that is usually absent at rest and present during posture and intentional movements.

ET can also involve the voice (62% of patients), the head (48% of patients), and jaw.[1][2][3]

History and exam

Key diagnostic factors

presence of risk factors
postural and/or kinetic tremor
problems with fine motor tasks

Full details

Other diagnostic factors

abatement of tremor after consumption of alcohol, benzodiazepines, barbiturates, or gabapentin
head or voice tremor
resting tremor

Full details

Risk factors

advanced age
family history
white ancestry
exposure to environmental toxins

Full details

Diagnostic investigations

1st investigations to order

clinical diagnosis

Full details

Investigations to consider

CT or MRI scan of the head
serum ceruloplasmin
24-hour urine copper
thyroid function tests
tremor physiology studies
single-photon emission CT (SPECT) scan of the head

Full details

Emerging tests

tremor stability index

Treatment algorithm

ACUTE

no dysfunction or embarrassment

dysfunction or embarrassment

Contributors

Authors

Sheng-Han Kuo, MD

H. Houston Merritt Associate Professor of Neurology

College of Physicians and Surgeons

Columbia University

New York

Disclosures

SHK is an author of a number of references cited in this topic.

Ming-Kai Pan, MD, PhD

Associate Professor of Pharmacology

College of Medicine

National Taiwan University

Taipei

Taiwan

Disclosures

MKP is a consultant of BioPro Scientific, Taiwan, and Sumitomo Pharma Co., Japan. MKP is an author of a number of references cited in this topic.

Acknowledgements

Dr Sheng-Han Kuo and Dr Ming-Kai Pan would like to gratefully acknowledge Dr Zoltan Mari, Dr Martin Kronenbuerger, Dr Adam Burdick, and Dr Kelly D. Foote, previous contributors to this topic.

Disclosures

ZM has directed various educational programmes, accredited (CME) by Johns Hopkins University, and has accepted honoraria for consulting. MK, AB, and KDF declare that they have no competing interests.

Peer reviewers

Katherine Longardner, MD

Assistant Clinical Professor

University of California San Diego

San Diego

Disclosures

KL was a paid consultant for Boston Scientific.

Roger Weis, MD

Pediatric Neurologist

Kinderneurologisches Zentrum Mainz

Mainz

Germany

Disclosures

RW declares that he has no competing interests.

Cory Toth, BSc, MD, FRCP(C)

Assistant Professor of Neurosciences

Hotchkiss Brain Institute

University of Calgary

Alberta

Canada

Disclosures

CT declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Deuschl G, Bain P, Brin M; Ad Hoc Scientific Committee. Consensus statement of the Movement Disorder Society on tremor. Mov Disord. 1998;13(suppl 3):2-23. Abstract

Ferreira JJ, Mestre TA, Lyons KE, et al. MDS evidence-based review of treatments for essential tremor. Mov Disord. 2019 Jul;34(7):950-8. Abstract

Zesiewicz TA, Elble RJ, Louis ED, et al. Evidence-based guideline update: treatment of essential tremor: report of the Quality Standards subcommittee of the American Academy of Neurology. Neurology. 2011 Nov 8;77(19):1752-5.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Parkinson's disease
- Dystonia
- Wilson's disease
More Differentials
Guidelines
- Suspected neurological conditions: recognition and referral
- American Society for Stereotactic and Functional Neurosurgery position statement on magnetic resonance-guided focused ultrasound for the management of essential tremor
More Guidelines
Patient information
Essential tremor
More Patient information
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Essential tremor

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Emerging tests

Treatment algorithm

no dysfunction or embarrassment

dysfunction or embarrassment

Contributors

Authors

Sheng-Han Kuo, MD

Disclosures

Ming-Kai Pan, MD, PhD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Katherine Longardner, MD

Disclosures

Roger Weis, MD

Disclosures

Cory Toth, BSc, MD, FRCP(C)

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice