Your reference guide for the most common movement disorder

Essential 

Tremor 

Patient 

Handbook

Your reference guide for the most 

common movement disorder.

What is essential tremor?

Essential tremor (ET) is one of the most common 

neurological conditions and the most common 

cause of tremor. Tremor is an involuntary, rhyth-

mic shaking of any part of the body. The hands 

are most commonly affected in ET, but the head, 

voice, legs, and trunk can also be affected.

The term essential, when used in a medical 

context, refers to a symptom that is isolated and 

does not have a specific underlying cause. Thus, 

ET refers to a disorder that displays the primary 

symptom of tremor, with no known cause. 

The tremor of ET is an action tremor and most 

commonly occurs while performing activities such 

as eating, drinking, writing, typing, brushing teeth, 

shaving, etc. (kinetic tremor) or when the hands 

are in an outstretched position (postural tremor). 

ET can therefore make it difficult to complete ev-

eryday tasks and can lead to significant disability. 

Some patients may present with a combination of 

tremors affecting different body parts. The sever-

ity of the tremor can vary from a barely notice-

able tremor only present in situations of stress 

or anxiety, to severe tremor that has a significant 

impact on activities of daily living. Tremor severity 

can vary based on the activity being performed, 

the position of the body part, and the presence 

of stress or fatigue. The tremor may worsen over 

time and may spread to parts of the body not pre-

viously affected. 

Who develops ET?

ET is estimated to affect up to 10 million people 

in the United States and many more worldwide. 

Men and women are equally affected and it occurs 

in people of all races. Although ET is most com-

monly seen in older adults, it may occur at any age 

from childhood to late adulthood. ET is hereditary 

in more than 50 percent of cases. It appears to 

be an autosomal dominant disease, which means 

that a child of a person with ET has a 50 percent 

chance of inheriting the disorder. Consequently, 

ET has been referred to as familial tremor. ET has 

also been called benign tremor, which is mislead-

ing, as ET is commonly a source of frustration or 

social embarrassment, and in some cases can be 

disabling. 

What causes ET?

The cause of ET is currently unknown. It is thought 

to be related to abnormal functioning of the part 

of the brain called the cerebellum or a chemical in 

the brain called GABA; however, no specific brain 

abnormalities have been confirmed. Although a 

large percentage of persons with ET have a family 

history of the disorder, a specific gene for ET has 

not been identified and therefore no genetic test for 

ET is currently available. In fact, not everyone who 

has a family member with ET develops ET. This 

suggests the possible influence of some not yet 

identified environmental factors. 

Although commonly seen in older adults, essential tremor can 

occur at any age. Ryan Brown was diagnosed at four years old.

How is ET diagnosed?

To avoid a misdiagnosis, it is important that you 

see a doctor who has been trained to diagnose 

and treat tremor. It is best to see a neurologist who 

specializes in movement disorders. There are no 

medical tests to confirm the diagnosis of ET. ET 

is diagnosed by medical history and neurologi-

cal evaluation. The neurological exam generally 

includes an examination of tremor in various body 

parts in different positions as well as completion of 

writing samples, pouring, and drawing Archimedes 

spirals, after which the physician evaluates symp-

toms and rules out other potential causes of tremor 

such as:

•  medication side effects,

•  thyroid disease,

•  excessive stress or trauma,

•  excessive use of caffeine or other stimulants,

•  presence of other movement disorders such 

as Parkinson’s disease (PD) and dystonia.

Archimedies spiral drawn 

by a patient receiving a 

trial dose of a medication.

Archimedies spiral drawn 

by a patient receiving a 

more effective dose of the 

same medication.

Archimedies spiral drawn 

by a patient receiving no 

medication.

How do I prepare for an ET  

neurological evaluation?

During the neurological evaluation, the doctor will 

ask you for complete medical and family history 

and specific information about your tremor. Here 

are some questions the doctor may ask during 

your visit:

•  Do you have a family history of tremor?

•  Does anyone in your family shake for any 

reason?

•  When did you first notice any type of shak-

ing (tremor) and did it begin after a particu-

lar incident?

•  What parts of your body are affected?

•  Did the tremor start suddenly? 

•  Has it worsened over time?

•  Are there specific factors that make your 

tremor worse such as stress, caffeine, or 

alcohol intake?

•  What effect does alcohol have on your 

tremor within a few minutes after ingestion, 

and the following morning?

•  Have you ever had a head injury?

•  Does your tremor occur during action or 

while you are at rest?

ET is diagnosed by medical history and 

neurological evaluation. 

•  What medications—over-the-counter 

vitamins, herbal supplements, and prescrip-

tions—are you taking and what medications 

have you taken in the past? (Certain medi-

cations may cause tremor, so it’s a good 

idea to bring a list of the medications you 

are taking or the pill containers themselves. 

It is also helpful to list any medications you 

have taken in the past.)

What are other causes of tremor?

Although ET is the most common cause of tremor, 

there are many other potential causes. Some ad-

ditional causes of tremor include:

• 

Enhanced physiologic tremor

 – Every-

one has a mild, barely detectable tremor 

referred to as a physiologic tremor. Dur-

ing situations causing stress, fear, anger, 

anxiety, or fatigue this tremor may become 

noticeable and is referred to as enhanced 

physiologic tremor.  

• 

Drug-induced tremor

 – Tremor can be a 

side effect of prescription medications, such 

as beta-adrenoceptor agonists, valproic 

acid, thyroxine, tricyclic antidepressants, 

selective serotonin reuptake inhibitors, 

amiodarone, procainamide, methylxan-

thines, antipsychotics, and lithium among 

others. Some over-the-counter medications, 

supplements, herbal remedies, and illegal 

drugs may also cause tremor. 

• 

Post-traumatic tremor

 – An injury to the 

head can cause tremor.  

• 

Other neurological disorders

 – Other 

than ET, the most common neurological 

disorders causing tremor are Parkinson’s 

disease and dystonia (involuntary muscle 

contractions), but tremor may also occur 

with multiple sclerosis or after a stroke. 

Do I have ET or Parkinson’s disease?

It is often difficult to differentiate ET from Parkin-

son’s disease (PD), particularly during the early 

stages of the disease. Consequently, many people 

are initially misdiagnosed. And to complicate the 

situation, it is possible to have more than one neu-

rological disorder. Here are some basic differences 

between ET and PD: 

• 

Type of tremor

 – The tremor in ET generally 

occurs with action, either while performing 

a task (kinetic tremor) or while holding the 

body part against gravity such as having 

the arms outstretched in front of the body 

(postural tremor). The tremor of PD most 

commonly occurs when the limb or other 

body part is at rest (resting tremor). 

Dr. Vincent DePinto retired from vascular surgery because his 

tremor interfered with his ability to preform delicate surgeries.

• 

Additional symptoms

 – The primary symp-

tom of ET is tremor. Although tremor is a 

primary symptom of PD, additional features, 

such as slowness, stiffness, balance prob-

lems, and shuffling gait are also generally 

present. 

• 

Body parts affected by tremor

 – ET and 

PD both involve tremor of the arms/hands, 

but head and voice tremor most commonly 

appear in ET and almost never in PD. 

• 

Handwriting

 – In ET handwriting is often 

large and shaky, whereas in PD, handwrit-

ing is often very small (micrographia).

• 

Family history

 – Persons with ET often 

have a family history of tremor, whereas in 

PD, family history of PD or tremor is much 

less common. 

• 

Alcohol 

– ET is often reduced by drinking 

alcohol whereas in PD, alcohol generally 

does not improve tremor.

• 

Medications

 – ET generally does not re-

spond to medications used for PD, and PD 

generally does not respond to medications 

used for ET.

What is DaTscan® and how can it help 

me?

DaTscan®

 is a neuroimaging tool (brain scan) 

that can assist in differentiating ET and PD, but it 

does not provide a definitive diagnosis for either 

disease. In cases where neurological examination 

is not sufficient to make a diagnosis of either ET or 

PD, DaTscan may be helpful. 

PD is related to a decrease in a chemical in the 

brain called dopamine. DaTscan® involves a 

picture of the brain using single photon emission 

computed tomography (SPECT), to measure 

dopamine transporter levels in the brain. In PD, an 

abnormal scan representing a reduction in dopa-

mine transporter levels is seen, whereas in ET the 

scan is normal. 

Figure 1 

compares the normal comma-shaped 

appearance on both sides of the brain of the 

DaTscan in ET (left) with the period-shaped ap-

pearance of the DaTscan in PD (right) due to 

reduced dopamine transporter levels. It is impor-

tant to understand that a normal DaTscan does not 

confirm a diagnosis of ET; it only helps to rule out a 

diagnosis of PD. 

What therapies are available for ET?

While a cure for ET has not yet been found, 

medications may help improve your quality of life. 

If your ET is mild and not bothersome to you, you 

may not need treatment. However, if ET interferes 

with your ability to work, perform daily activities, or 

interact socially, you may want to consider avail-

able therapies. The goal of treatment is to reduce 

Figure 1

the severity of tremor to improve daily functioning 

such as eating, drinking, writing, and typing, as 

well as to reduce social embarrassment. 

Medications are estimated to be effective for about 

50 percent of patients and they rarely completely 

eliminate tremor; therefore, it is important for you 

to have realistic expectations about drug therapy. 

Each person responds differently to the various 

treatment options, so it may take time to find the 

treatment that is best for you. You may need to 

try more than one treatment or use a combination 

of treatments before you and your physician find 

what works best for you.

First-line therapies

Propranolol (Inderal®, Inderal-LA®)

Propranolol is currently the only medication ap-

proved by the Food and Drug Administration (FDA) 

for the treatment of ET. Propranolol is in a class of 

drugs called beta-blockers, which are used primar-

ily for treating high blood pressure. These drugs 

block adrenaline in the nervous system; however, it 

is not clear exactly how propranolol works in treat-

ing ET. Propranolol is effective in reducing tremor 

in approximately 50 to 60 percent of persons with 

ET. 

Your doctor may prescribe propranolol to be taken 

as needed, such as during particularly stressful 

situations, or it may be taken daily if your disability 

is persistent. Tremor reduction generally occurs 

one to two hours after a single 10 to 40 milligram 

(mg) dose, and the effect generally lasts about four 

hours. A once-daily, long-acting preparation is also 

available. Although propranolol is most effective 

for hand tremor, it may also be effective for head 

and voice tremor. Individual response varies, and 

complete tremor reduction is rare. Side effects of 

propranolol are usually mild and are more frequent 

at higher doses (more than 120 mg/day). The main 

side effects are decreased pulse rate and low 

blood pressure. Less common side effects are fa-

tigue, depression, impotence, nausea, weight gain, 

rash, and diarrhea. If you experience unpleasant 

side effects, be sure to talk with your doctor. If you 

have heart failure, diabetes mellitus, or asthma, 

you should talk with your general medical doctor 

before you take propranolol.

Propranolol is typically started in divided doses 

from 10 to 60 mg/day. While most patients benefit 

from doses less than 120 mg/day, the daily dose 

can be increased up to 320 mg if necessary. No 

additional benefit has been seen in doses greater 

than 320 mg/day. Older patients should start 

with 10 mg/day, and the dose should be slowly 

increased to 80 to100 mg/day. Propranolol long- 

acting should be started at 60 mg/day and can 

be slowly increased to 120 mg/day or higher as 

needed and tolerated. Do not abruptly stop this 

medication without first talking with your physician. 

Other beta-blockers such as atenolol, metoprolol, 

and nadolol may also be beneficial for ET.

Natalie Kusilek, IETF member since 1999, with her daughter Teri. 

Natalie has struggled to find a treatment option that helps  

control her head tremor.

Primidone (Mysoline®)

Primidone is an anti-seizure medicine that is often 

used to treat ET.  Approximately 60 percent of 

people with ET are helped by primidone, and the 

benefit usually lasts 24 hours after each dose. 

When you first start taking primidone, you may ex-

perience nausea, poor balance, dizziness, fatigue, 

drowsiness, and flu-like symptoms that generally 

subside after a couple of days. You can reduce the 

possibility for these symptoms by starting with a 

small dose at bedtime and gradually increasing the 

dose until tremor is suppressed. If you experience 

more serious side effects, you should contact your 

doctor. Although primidone may have initial side 

effects, there are few long-term problems. 

Primidone dosage typically starts at 12.5 mg (one 

quarter of a 50 mg tablet) or 25 mg (half a 50 mg 

tablet) at bedtime. After one week, the dose can 

be increased to 50 mg at bedtime. The dose can 

then be increased by 50 mg a week, typically up 

to a dose of 250 mg/day or until adequate tremor 

control is achieved. Doses of up to 750 mg/day 

provide benefit in some patients. Primidone can 

be taken as a single dose at bedtime, particularly 

if sleepiness is a problem, or it can be taken in 

divided doses throughout the day.

Combination of Propranolol and Primidone

If your tremor is not well controlled by propranolol 

or by primidone alone, you may experience better 

results when you take both medicines together.

Benzodiazepines

Clonazepam (Klonopin®), diazepam (Valium®), lo-

razepam (Ativan®), and alprazolam (Xanax®) are 

frequently used to treat ET. These drugs are es-

pecially helpful in patients with associated anxiety. 

Although diazepam has been shown to improve 

tremor, it is typically not as effective as propranolol 

and primidone. Alprazolam has been shown to 

significantly reduce tremor as well as symptoms of 

anxiety. The effectiveness of alprazolam has been 

found to be equal to that of primidone. 

If benzodiazepines are used for long periods in 

large dosages, they can become addictive. There 

is also risk of withdrawal symptoms if the drugs are 

stopped suddenly. These drugs may be particu-

larly useful in patients who do not respond to other 

medications or who have associated anxiety. Side 

effects include sleepiness, dizziness, depression, 

fatigue, loss of coordination, memory loss, and 

confusion.

Second-line therapies

Gabapentin (Neurontin®)

Gabapentin is an anticonvulsant. It has a modest 

benefit in ET and is often tried when proprano-

lol and primidone are not effective. Gabapentin 

is generally well tolerated. Side effects include 

fatigue, slurred speech, drowsiness, impaired 

balance, and nausea, especially when begin-

ning treatment. The drug has a short duration of 

action and requires multiple doses a day. In older 

persons, gabapentin is typically started at 100 mg 

three times daily; in younger persons it is often 

started at 300 mg three times daily.

Topiramate (Topamax®)

Topiramate is an anticonvulsant that has been 

shown to be effective in controlling tremor in some 

Take your medications exactly as  

prescribed by your physician.

persons with ET. Starting with a low initial dosage 

and slowly increasing the dosage over time can 

minimize side effects. Dosages should be started 

at 25 mg or 50 mg at night for the first week, and 

increased by 25 to 50 mg/day each week, depend-

ing on side effects, up to a total dose of 300 to 400 

mg/day. Side effects include numbness or tingling 

(paresthesia), memory loss, and weight loss.  Topi-

ramate should be avoided in patients with a history 

of kidney stones and should be used with caution 

in the elderly due to an increased risk of memory 

problems and confusion. 

Mirtazapine (Remeron®)

Mirtazapine is an antidepressant. Due to its lack of 

effectiveness for the majority of persons with ET 

and its significant side effects, mirtazapine is not 

recommended for the routine treatment of ET. Ad-

verse effects include confusion, dry mouth, weight 

gain, frequent urination, balance and gait difficulty, 

nausea, and blurred vision.

Botulinum Toxin Injections

If medications fail, you may consider therapy that 

involves injecting botulinum toxin into the affected 

muscles. Botulinum toxin injections have been 

useful in the treatment of some patients with hand, 

head, and voice tremor. Receiving optimal benefit 

from botulinum toxin requires a specialist skilled 

in the technique. The effects last about three to 

four months and, for continued benefit, must be 

repeated about three times a year. Transient weak-

ness of the injected muscles is the most common 

side effect. Be sure to check with your insurance 

provider about coverage, as this treatment can be 

expensive.

Surgical Therapies

If medical treatment is not successful and your 

tremor continues to cause disability, surgical alter-

natives such as deep brain stimulation (DBS) of 

the thalamus or thalamotomy might be an option. 

You can learn more about surgical treatments for 

ET in “Surgical Treatment of Essential Tremor,” 

which is available from the IETF office.

What is the effect of alcohol on ET? 

Adults with ET often notice that drinking alcohol 

reduces tremor for one to two hours. When you 

use alcohol responsibly, it can be very effective in 

temporarily reducing tremor. It may even be helpful 

to have one or two drinks during social events to 

suppress tremor. There are, however, important is-

sues to consider in using alcohol for ET. Rebound 

tremor may occur after excessive alcohol use, 

making tremor temporarily more severe the next 

day. If you use alcohol to reduce tremor, be sure 

to talk with your doctor about it. You should avoid 

excessive use of alcohol, and never consume al-

cohol if you plan to drive. The limitations of the use 

Elizabeth Guthrie, support group leader and artist, opted for DBS 

surgery when medications no longer controlled her tremor.

of alcohol as a treatment for ET include the short 

duration of response, development of tolerance to 

the anti-tremor effect, increased tremor as alcohol 

is metabolized, and the risk of alcoholism. 

What other tactics might help me man-

age my ET?

While the following do not have proven effective-

ness for ET, some people with ET have found 

them to be beneficial: 

• 

Occupational therapy

 – An occupational 

therapist can provide helpful techniques or 

introduce devices to make living with ET 

more manageable. Some examples include 

using heavier utensils, cups, and glasses; 

wrist weights; plate guards; heavier, wider 

writing instruments; and other adaptive 

devices such as a special computer mouse 

that compensates for tremor, or computer 

voice recognition programs that greatly 

reduce the need for typing.

Kate Larson is a horse trainer and riding instructor.  

For Kate, it isn’t about how ET limits her; it’s about what she  

can accomplish despite her tremor.

• 

Alternative treatments

 – Many people 

have tried treatments such as acupuncture, 

hypnosis, meditation, yoga, and massage 

therapy with unconfirmed benefit. These 

treatments may be particularly helpful 

in persons with anxiety. Biofeedback or 

behavioral therapy may also be helpful for 

persons dealing with high levels of stress 

or anxiety. There are currently no specific 

vitamins or supplements recommended to 

reduce tremor. 

Practical suggestions

There are many ways to minimize the degree to 

which ET interferes with your life. Here are some 

practical suggestions:

•  Learn as much as you can about ET. You 

are your own best advocate.

•  ET is commonly misdiagnosed. Make sure 

your physician is knowledgeable about ET 

and is actively working with you to control 

your tremor. Our website provides a list of 

physicians with experience treating ET and 

other movement disorders.

•  Don’t hide your tremor. Talk about it to 

friends, relatives, and colleagues. Creat-

ing greater awareness about your tremor 

can greatly reduce your anxiety and may 

consequently reduce your tremor. Not only 

will you make yourself more comfortable 

around others, but they will be more com-

fortable around you! The more everyone 

learns about ET, the faster public aware-

ness will increase. Greater awareness will 

bring attention to ET and facilitate research 

so additional treatments and a cure can be 

discovered.

•  If your child has ET, you may want to meet 

with his/her teacher(s) to discuss. Order 

the free IETF booklet “Children with Essen-

tial Tremor: A guide for parents, teachers 

and other caring adults” and share it with 

your child’s teacher. “Tremor Disorders in 

Children: A Clinical Discussion” is an IETF 

booklet you may want to share with your 

physician.

•  Find ways to reduce stress and learn some 

relaxation techniques. Anxiety and depres-

sion are common in ET.

•  Avoid things that may worsen tremor such 

as caffeine, some herbal remedies, and 

certain prescription medications.

•  You can find many more ideas by calling the 

IETF and asking for the flyer “Coping with 

Essential Tremor.”

•  Join a support group or learn how to be-

come a leader. The IETF provides informa-

tion about joining or starting an ET support 

group. A list of groups is also available on 

the IETF website: www.essentialtremor.org.

Acknowledgements

For generously giving their time and expertise to write and review the 

information presented in this handbook, the IETF extends special 

thanks to Arif Dalvi, MD, Director of the Movement Disorders Program 

at the Neuroscience Institute at Methodist Hospital, Merrillville, Indiana, 

and Clinical Associate Professor of Neurology at the University of 

Chicago Pritzker School of Medicine, Glenview, Illinois;  Rodger 

Elble, MD, PhD, Professor and Chair of Neurology, Department of 

Neurology at the Southern Illinois University School of Medicine, 

Springfield, Illinois; and Kelly E Lyons, PhD, Director of Research for the 

Parkinson’s Disease and Movement Disorders Center at the University 

of Kansas Medical Center, Kansas City, Kansas.

Resources

For more information about ET, call the IETF 

toll-free at 888-387-3667 or visit the website: 

www.essentialtremor.org

Join us on Facebook: https://www.facebook.com/

InternationalEssentialTremorFoundation

Follow us on Twitter:  

http://twitter.com/essentialtremor

Sign up for the monthly electronic newsletter, 

Tremor Gram, at www.essentialtremor.org 

Participate in the forums of our online blog: 

 www.tremortalk.org

My Important Information

My doctor:

 _________________________

Phone:

 ___________________________

My neurologist:

______________________

Phone:

 ___________________________

My medication(s):

_____________________

 ________________________________

This information is not intended to replace your current medical 

therapy. Discuss your difficulties with your physician or other 

healthcare professional in order to help develop a well-rounded 

treatment plan that is right for you.

PO Box 14005

Lenexa, KS 66285-4005

Toll free [phone] 

Local area [phone] 

Facsimilie [phone]

[e-mail]

ESSENTIALTREMOR.ORG

Facebook.com/InternationalEssentialTremorFoundation

Twitter.com/essentialtremor

Blog: TremorTalk.org

The International Essential Tremor Foundation 

is a 501(c)(3) non-profit organization that funds 

research to find the cause of essential tremor 

that leads to treatments and a cure, increases 

awareness, and provides educational materials, 

tools, and support for healthcare providers, the 

public, and those affected by ET.

International 

Essential Tremor 

Foundation (IETF)