Skip to main content
Postgraduate Medical Journal logoLink to Postgraduate Medical Journal
. 2005 Dec;81(962):756–762. doi: 10.1136/pgmj.2005.032979

Differential diagnosis of common tremor syndromes

R Bhidayasiri 1
PMCID: PMC1743400  PMID: 16344298

Abstract

Tremor is one of the most common involuntary movement disorders seen in clinical practice. In addition to the detailed history, the differential diagnosis is mainly clinical based on the distinction at rest, postural and intention, activation condition, frequency, and topographical distribution. The causes of tremor are heterogeneous and it can present alone (for example, essential tremor) or as a part of a neurological syndrome (for example, multiple sclerosis). Essential tremor and the tremor of Parkinson's disease are the most common tremors encountered in clinical practice. This article focuses on a practical approach to these different forms of tremor and how to distinguish them clinically. Evidence supporting various strategies used in the differentiation is then presented, followed by a review of formal guidelines or recommendations when they exist.

Full Text

The Full Text of this article is available as a PDF (268.6 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Asenbaum S., Pirker W., Angelberger P., Bencsits G., Pruckmayer M., Brücke T. [123I]beta-CIT and SPECT in essential tremor and Parkinson's disease. J Neural Transm (Vienna) 1998;105(10-12):1213–1228. doi: 10.1007/s007020050124. [DOI] [PubMed] [Google Scholar]
  2. Bain P. G., Findley L. J., Thompson P. D., Gresty M. A., Rothwell J. C., Harding A. E., Marsden C. D. A study of hereditary essential tremor. Brain. 1994 Aug;117(Pt 4):805–824. doi: 10.1093/brain/117.4.805. [DOI] [PubMed] [Google Scholar]
  3. Benamer T. S., Patterson J., Grosset D. G., Booij J., de Bruin K., van Royen E., Speelman J. D., Horstink M. H., Sips H. J., Dierckx R. A. Accurate differentiation of parkinsonism and essential tremor using visual assessment of [123I]-FP-CIT SPECT imaging: the [123I]-FP-CIT study group. Mov Disord. 2000 May;15(3):503–510. [PubMed] [Google Scholar]
  4. Bharucha N. E., Bharucha E. P., Bharucha A. E., Bhise A. V., Schoenberg B. S. Prevalence of Parkinson's disease in the Parsi community of Bombay, India. Arch Neurol. 1988 Dec;45(12):1321–1323. doi: 10.1001/archneur.1988.00520360039008. [DOI] [PubMed] [Google Scholar]
  5. Boller F., Ganansia-Ganem A., Lebert F., Pasquier F. Neuropsychiatric afflictions of modern French presidents: Marechal Henri-Philippe Petain and Paul Deschanel. Eur J Neurol. 1999 Mar;6(2):133–136. doi: 10.1111/j.1468-1331.1999.tb00005.x. [DOI] [PubMed] [Google Scholar]
  6. Brin M. F., Koller W. Epidemiology and genetics of essential tremor. Mov Disord. 1998;13 (Suppl 3):55–63. doi: 10.1002/mds.870131310. [DOI] [PubMed] [Google Scholar]
  7. Brin M. F., Lyons K. E., Doucette J., Adler C. H., Caviness J. N., Comella C. L., Dubinsky R. M., Friedman J. H., Manyam B. V., Matsumoto J. Y. A randomized, double masked, controlled trial of botulinum toxin type A in essential hand tremor. Neurology. 2001 Jun 12;56(11):1523–1528. doi: 10.1212/wnl.56.11.1523. [DOI] [PubMed] [Google Scholar]
  8. Cho J. W., Chu K., Jeon B. S. Case of essential palatal tremor: atypical features and remarkable benefit from botulinum toxin injection. Mov Disord. 2001 Jul;16(4):779–782. doi: 10.1002/mds.1132. [DOI] [PubMed] [Google Scholar]
  9. Chouinard S., Louis E. D., Fahn S. Agreement among movement disorder specialists on the clinical diagnosis of essential tremor. Mov Disord. 1997 Nov;12(6):973–976. doi: 10.1002/mds.870120621. [DOI] [PubMed] [Google Scholar]
  10. Cleeves L., Findley L. J. Propranolol and propranolol-LA in essential tremor: a double blind comparative study. J Neurol Neurosurg Psychiatry. 1988 Mar;51(3):379–384. doi: 10.1136/jnnp.51.3.379. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Comby B., Chevalier G., Bouchoucha M. A new method for the measurement of tremor at rest. Arch Int Physiol Biochim Biophys. 1992 Jan-Feb;100(1):73–78. doi: 10.3109/13813459209035262. [DOI] [PubMed] [Google Scholar]
  12. Connor Gregory S. A double-blind placebo-controlled trial of topiramate treatment for essential tremor. Neurology. 2002 Jul 9;59(1):132–134. doi: 10.1212/wnl.59.1.132. [DOI] [PubMed] [Google Scholar]
  13. Demirkiran M., Jankovic J., Dean J. M. Ecstasy intoxication: an overlap between serotonin syndrome and neuroleptic malignant syndrome. Clin Neuropharmacol. 1996 Apr;19(2):157–164. doi: 10.1097/00002826-199619020-00004. [DOI] [PubMed] [Google Scholar]
  14. Deuschl G., Bain P., Brin M. Consensus statement of the Movement Disorder Society on Tremor. Ad Hoc Scientific Committee. Mov Disord. 1998;13 (Suppl 3):2–23. doi: 10.1002/mds.870131303. [DOI] [PubMed] [Google Scholar]
  15. Deuschl G., Elble R. J. The pathophysiology of essential tremor. Neurology. 2000;54(11 Suppl 4):S14–S20. [PubMed] [Google Scholar]
  16. Deuschl G., Köster B., Lücking C. H., Scheidt C. Diagnostic and pathophysiological aspects of psychogenic tremors. Mov Disord. 1998 Mar;13(2):294–302. doi: 10.1002/mds.870130216. [DOI] [PubMed] [Google Scholar]
  17. Deuschl G., Raethjen J., Lindemann M., Krack P. The pathophysiology of tremor. Muscle Nerve. 2001 Jun;24(6):716–735. doi: 10.1002/mus.1063. [DOI] [PubMed] [Google Scholar]
  18. Deuschl G., Toro C., Hallett M. Symptomatic and essential palatal tremor. 2. Differences of palatal movements. Mov Disord. 1994 Nov;9(6):676–678. doi: 10.1002/mds.870090615. [DOI] [PubMed] [Google Scholar]
  19. Deuschl G., Toro C., Valls-Solé J., Zeffiro T., Zee D. S., Hallett M. Symptomatic and essential palatal tremor. 1. Clinical, physiological and MRI analysis. Brain. 1994 Aug;117(Pt 4):775–788. doi: 10.1093/brain/117.4.775. [DOI] [PubMed] [Google Scholar]
  20. Deuschl G., Wenzelburger R., Löffler K., Raethjen J., Stolze H. Essential tremor and cerebellar dysfunction clinical and kinematic analysis of intention tremor. Brain. 2000 Aug;123(Pt 8):1568–1580. doi: 10.1093/brain/123.8.1568. [DOI] [PubMed] [Google Scholar]
  21. Dietrichson P., Espen E. Effects of timolol and atenolol on benign essential tremor: placebo-controlled studies based on quantitative tremor recording. J Neurol Neurosurg Psychiatry. 1981 Aug;44(8):677–683. doi: 10.1136/jnnp.44.8.677. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Elble R. J. Diagnostic criteria for essential tremor and differential diagnosis. Neurology. 2000;54(11 Suppl 4):S2–S6. [PubMed] [Google Scholar]
  23. Elble R. J. Essential tremor frequency decreases with time. Neurology. 2000 Nov 28;55(10):1547–1551. doi: 10.1212/wnl.55.10.1547. [DOI] [PubMed] [Google Scholar]
  24. Finsterer J., Muellbacher W., Mamoli B. Yes/yes head tremor without appendicular tremor after bilateral cerebellar infarction. J Neurol Sci. 1996 Aug;139(2):242–245. [PubMed] [Google Scholar]
  25. Gorman W. P., Cooper R., Pocock P., Campbell M. J. A comparison of primidone, propranolol, and placebo in essential tremor, using quantitative analysis. J Neurol Neurosurg Psychiatry. 1986 Jan;49(1):64–68. doi: 10.1136/jnnp.49.1.64. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Grimes D. A. Tremor--easily seen but difficult to describe and treat. Can J Neurol Sci. 2003 Mar;30 (Suppl 1):S59–S63. doi: 10.1017/s0317167100003255. [DOI] [PubMed] [Google Scholar]
  27. Gulcher J. R., Jónsson P., Kong A., Kristjánsson K., Frigge M. L., Kárason A., Einarsdóttir I. E., Stefánsson H., Einarsdóttir A. S., Sigurthoardóttir S. Mapping of a familial essential tremor gene, FET1, to chromosome 3q13. Nat Genet. 1997 Sep;17(1):84–87. doi: 10.1038/ng0997-84. [DOI] [PubMed] [Google Scholar]
  28. Haerer A. F., Anderson D. W., Schoenberg B. S. Prevalence of essential tremor. Results from the Copiah County study. Arch Neurol. 1982 Dec;39(12):750–751. doi: 10.1001/archneur.1982.00510240012003. [DOI] [PubMed] [Google Scholar]
  29. Higgins J. J., Pho L. T., Nee L. E. A gene (ETM) for essential tremor maps to chromosome 2p22-p25. Mov Disord. 1997 Nov;12(6):859–864. doi: 10.1002/mds.870120605. [DOI] [PubMed] [Google Scholar]
  30. Hughes A. J., Lees A. J., Stern G. M. Apomorphine in the diagnosis and treatment of parkinsonian tremor. Clin Neuropharmacol. 1990 Aug;13(4):312–317. doi: 10.1097/00002826-199008000-00005. [DOI] [PubMed] [Google Scholar]
  31. Jankovic Joseph. Essential tremor: a heterogenous disorder. Mov Disord. 2002 Jul;17(4):638–644. doi: 10.1002/mds.10221. [DOI] [PubMed] [Google Scholar]
  32. Jefferson D., Jenner P., Marsden C. D. beta-Adrenoreceptor antagonists in essential tremor. J Neurol Neurosurg Psychiatry. 1979 Oct;42(10):904–909. doi: 10.1136/jnnp.42.10.904. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Karas B. J., Wilder B. J., Hammond E. J., Bauman A. W. Valproate tremors. Neurology. 1982 Apr;32(4):428–432. doi: 10.1212/wnl.32.4.428. [DOI] [PubMed] [Google Scholar]
  34. Kim Y. J., Pakiam A. S., Lang A. E. Historical and clinical features of psychogenic tremor: a review of 70 cases. Can J Neurol Sci. 1999 Aug;26(3):190–195. doi: 10.1017/s0317167100000238. [DOI] [PubMed] [Google Scholar]
  35. Koller W. C. Dose-response relationship of propranolol in the treatment of essential tremor. Arch Neurol. 1986 Jan;43(1):42–43. doi: 10.1001/archneur.1986.00520010038018. [DOI] [PubMed] [Google Scholar]
  36. Koller W. C., Hubble J. P. Levodopa therapy in Parkinson's disease. Neurology. 1990 Oct;40(10 Suppl 3):suppl 40–49. [PubMed] [Google Scholar]
  37. Koller W. C. Pharmacologic treatment of parkinsonian tremor. Arch Neurol. 1986 Feb;43(2):126–127. doi: 10.1001/archneur.1986.00520020020009. [DOI] [PubMed] [Google Scholar]
  38. Koller W. C., Royse V. L. Efficacy of primidone in essential tremor. Neurology. 1986 Jan;36(1):121–124. doi: 10.1212/wnl.36.1.121. [DOI] [PubMed] [Google Scholar]
  39. Koller W., Cone S., Herbster G. Caffeine and tremor. Neurology. 1987 Jan;37(1):169–172. doi: 10.1212/wnl.37.1.169. [DOI] [PubMed] [Google Scholar]
  40. Koller W., Lang A., Vetere-Overfield B., Findley L., Cleeves L., Factor S., Singer C., Weiner W. Psychogenic tremors. Neurology. 1989 Aug;39(8):1094–1099. doi: 10.1212/wnl.39.8.1094. [DOI] [PubMed] [Google Scholar]
  41. Koller W., Pahwa R., Busenbark K., Hubble J., Wilkinson S., Lang A., Tuite P., Sime E., Lazano A., Hauser R. High-frequency unilateral thalamic stimulation in the treatment of essential and parkinsonian tremor. Ann Neurol. 1997 Sep;42(3):292–299. doi: 10.1002/ana.410420304. [DOI] [PubMed] [Google Scholar]
  42. Korczyn A. D., Brunt E. R., Larsen J. P., Nagy Z., Poewe W. H., Ruggieri S. A 3-year randomized trial of ropinirole and bromocriptine in early Parkinson's disease. The 053 Study Group. Neurology. 1999 Jul 22;53(2):364–370. doi: 10.1212/wnl.53.2.364. [DOI] [PubMed] [Google Scholar]
  43. Larsen T. A., Calne D. B. Essential tremor. Clin Neuropharmacol. 1983;6(3):185–206. doi: 10.1097/00002826-198309000-00002. [DOI] [PubMed] [Google Scholar]
  44. Limousin P., Speelman J. D., Gielen F., Janssens M. Multicentre European study of thalamic stimulation in parkinsonian and essential tremor. J Neurol Neurosurg Psychiatry. 1999 Mar;66(3):289–296. doi: 10.1136/jnnp.66.3.289. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Louis E. D., Barnes L. F., Ford B., Pullman S. L., Yu Q. Ethnic differences in essential tremor. Arch Neurol. 2000 May;57(5):723–727. doi: 10.1001/archneur.57.5.723. [DOI] [PubMed] [Google Scholar]
  46. Louis E. D. Clinical practice. Essential tremor. N Engl J Med. 2001 Sep 20;345(12):887–891. doi: 10.1056/NEJMcp010928. [DOI] [PubMed] [Google Scholar]
  47. Louis E. D., Ford B., Barnes L. F. Clinical subtypes of essential tremor. Arch Neurol. 2000 Aug;57(8):1194–1198. doi: 10.1001/archneur.57.8.1194. [DOI] [PubMed] [Google Scholar]
  48. Louis E. D., Ford B., Frucht S., Barnes L. F., X-Tang M., Ottman R. Risk of tremor and impairment from tremor in relatives of patients with essential tremor: a community-based family study. Ann Neurol. 2001 Jun;49(6):761–769. doi: 10.1002/ana.1022. [DOI] [PubMed] [Google Scholar]
  49. Nandi Dipankar, Aziz Tipu Z. Deep brain stimulation in the management of neuropathic pain and multiple sclerosis tremor. J Clin Neurophysiol. 2004 Jan-Feb;21(1):31–39. doi: 10.1097/00004691-200401000-00005. [DOI] [PubMed] [Google Scholar]
  50. Navan Prithiva, Findley Leslie J., Jeffs Jim A. R., Pearce Ronald K. B., Bain Peter G. Double-blind, single-dose, cross-over study of the effects of pramipexole, pergolide, and placebo on rest tremor and UPDRS part III in Parkinson's disease. Mov Disord. 2003 Feb;18(2):176–180. doi: 10.1002/mds.10320. [DOI] [PubMed] [Google Scholar]
  51. Ondo W., Hunter C., Vuong K. D., Schwartz K., Jankovic J. Gabapentin for essential tremor: a multiple-dose, double-blind, placebo-controlled trial. Mov Disord. 2000 Jul;15(4):678–682. doi: 10.1002/1531-8257(200007)15:4<678::aid-mds1012>3.0.co;2-0. [DOI] [PubMed] [Google Scholar]
  52. Onofrj M., Thomas A., Paci C., D'Andreamatteo G. Gabapentin in orthostatic tremor: results of a double-blind crossover with placebo in four patients. Neurology. 1998 Sep;51(3):880–882. doi: 10.1212/wnl.51.3.880. [DOI] [PubMed] [Google Scholar]
  53. Pizzuti G. P., Byford G. H., Cifaldi S., Salvatori G., Nolfe G. Finger tremor and the central nervous system. J Biomed Eng. 1992 Jul;14(4):356–359. doi: 10.1016/0141-5425(92)90011-9. [DOI] [PubMed] [Google Scholar]
  54. Pogarell O., Gasser T., van Hilten J. J., Spieker S., Pollentier S., Meier D., Oertel W. H. Pramipexole in patients with Parkinson's disease and marked drug resistant tremor: a randomised, double blind, placebo controlled multicentre study. J Neurol Neurosurg Psychiatry. 2002 Jun;72(6):713–720. doi: 10.1136/jnnp.72.6.713. [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Rautakorpi I., Takala J., Marttila R. J., Sievers K., Rinne U. K. Essential tremor in a Finnish population. Acta Neurol Scand. 1982 Jul;66(1):58–67. doi: 10.1111/j.1600-0404.1982.tb03129.x. [DOI] [PubMed] [Google Scholar]
  56. Roberts Eve A., Schilsky Michael L., Division of Gastroenterology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada A practice guideline on Wilson disease. Hepatology. 2003 Jun;37(6):1475–1492. doi: 10.1053/jhep.2003.50252. [DOI] [PubMed] [Google Scholar]
  57. Samie M. R., Selhorst J. B., Koller W. C. Post-traumatic midbrain tremors. Neurology. 1990 Jan;40(1):62–66. doi: 10.1212/wnl.40.1.62. [DOI] [PubMed] [Google Scholar]
  58. Sandyk R. Successful treatment of cerebellar tremor with clonazepam. Clin Pharm. 1985 Nov-Dec;4(6):615–618. [PubMed] [Google Scholar]
  59. Schrag A., Keens J., Warner J., Ropinirole Study Group Ropinirole for the treatment of tremor in early Parkinson's disease. Eur J Neurol. 2002 May;9(3):253–257. doi: 10.1046/j.1468-1331.2002.00392.x. [DOI] [PubMed] [Google Scholar]
  60. Schrag A., Münchau A., Bhatia K. P., Quinn N. P., Marsden C. D. Essential tremor: an overdiagnosed condition? J Neurol. 2000 Dec;247(12):955–959. doi: 10.1007/s004150070053. [DOI] [PubMed] [Google Scholar]
  61. Stacy M., Jankovic J. Tardive tremor. Mov Disord. 1992;7(1):53–57. doi: 10.1002/mds.870070110. [DOI] [PubMed] [Google Scholar]
  62. Thach W. T., Goodkin H. P., Keating J. G. The cerebellum and the adaptive coordination of movement. Annu Rev Neurosci. 1992;15:403–442. doi: 10.1146/annurev.ne.15.030192.002155. [DOI] [PubMed] [Google Scholar]
  63. Trelles L., Trelles J. O., Castro C., Altamirano J., Benzaquen M. Successful treatment of two cases of intention tremor with clonazepam. Ann Neurol. 1984 Nov;16(5):621–621. doi: 10.1002/ana.410160516. [DOI] [PubMed] [Google Scholar]
  64. Uddin Mohammad K., Rodnitzky Robert L. Tremor in children. Semin Pediatr Neurol. 2003 Mar;10(1):26–34. doi: 10.1016/s1071-9091(02)00006-2. [DOI] [PubMed] [Google Scholar]
  65. Vestergaard P. Clinically important side effects of long-term lithium treatment: a review. Acta Psychiatr Scand Suppl. 1983;305:1–36. [PubMed] [Google Scholar]
  66. Wasielewski P. G., Burns J. M., Koller W. C. Pharmacologic treatment of tremor. Mov Disord. 1998;13 (Suppl 3):90–100. doi: 10.1002/mds.870131316. [DOI] [PubMed] [Google Scholar]
  67. Wills A. J., Jenkins I. H., Thompson P. D., Findley L. J., Brooks D. J. A positron emission tomography study of cerebral activation associated with essential and writing tremor. Arch Neurol. 1995 Mar;52(3):299–305. doi: 10.1001/archneur.1995.00540270095025. [DOI] [PubMed] [Google Scholar]
  68. Wilms H., Sievers J., Deuschl G. Animal models of tremor. Mov Disord. 1999 Jul;14(4):557–571. doi: 10.1002/1531-8257(199907)14:4<557::aid-mds1004>3.0.co;2-g. [DOI] [PubMed] [Google Scholar]
  69. Wishart H. A., Roberts D. W., Roth R. M., McDonald B. C., Coffey D. J., Mamourian A. C., Hartley C., Flashman L. A., Fadul C. E., Saykin A. J. Chronic deep brain stimulation for the treatment of tremor in multiple sclerosis: review and case reports. J Neurol Neurosurg Psychiatry. 2003 Oct;74(10):1392–1397. doi: 10.1136/jnnp.74.10.1392. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Postgraduate Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES