Teachings in Tremors
Teachings in Tremors
Tremor is one of the more noticeable neurological conditions. We have all seen friends, relatives, and strangers with shaky hands or heads. Frequently, people will assume someone may have Parkinson’s, is very anxious, or enjoyed a few too many the night before at the local bar. As a neurologist, we are trained to be very observant and diagnosing a type of tremor can sometimes be done with this simple skill. This explains why most neurologists will get their own patients from the waiting room and walk you to the exam room. There is a lot to be gained from watching a patient respond to their name, get up out of the chair, and walk down the hallway. You may not realize it, but when you see a neurologist your examination starts when we call your name.
There are many causes and types of tremor. I will mainly discuss essential tremor, saving Parkinson’s for a later blog. Essential tremor, also called action tremor or benign familial tremor, is a high frequency, low amplitude tremor that is present with activities. Imagine a nervous waiter carrying a cup of coffee on a saucer and you have the right idea. This is the opposite of a Parkinson’s tremor which is a rolling tremor at rest. It is variable and worse with stress, caffeine, or lack of sleep. You may also find that a glass of wine reduces it. Essential tremor is the most noticeable in the hands, but can be present in the head, voice, or legs.
Sometimes, I can diagnose the tremor just by the patient’s handwriting on the patient forms. The forms will look like they were filled out while riding in the back of a pickup truck down a long gravel road. The handwriting of Parkinson’s patients is small but neat. Most importantly with essential tremor, there are no slow movements or shuffling walking that we see in Parkinson’s. Also essential tremor is typically present for years or even decades before seeing a neurologist and is much more likely to run in the family. As with Parkinson’s disease, a brain scan is not helpful in determining your diagnosis.
Your tremor may not represent an underlying neurological disease at all. It can be due to a side effect to medication or other substances. Once again, detective work remains very important. If your tremor started after a new medication, then chances are it is due to that medication. In the reverse way, I have had patients who took beta blockers for years for their blood pressure and a tremor was noted when the beta blocker was stopped. What this means is they have had essential tremor that had been treated by the beta blocker. The tremor can also be due to a medical condition such as hyperthyroidism.
While I’m not the oldest neurologist you’ve ever seen, treatment for essential tremor has not changed since I first learned about it. There are two main treatments. The first are beta blockers such as propranolol or Nadolol. The other is an older seizure medication called primidone. These medications can also be used in combination for the worse cases. Topiramate can also help and in the worst cases, deep brain stimulation can help essential tremor. Due to side effects and the difficult nature of tremors, the goal of treatment is to reduce but not eliminate the tremor.
For the vast majority of people, essential tremor is a nuisance and will not lead to disability. Frequently patients will decide it is time to seek medical attention when the tremor interfering with activities or they find it socially unacceptable. A lot of patients just want to make sure they don’t have Parkinson’s disease. The information contained in this article does not replace proper medical care. As always, proper diagnosis and treatment of your tremor should be performed by a neurologist.