Diagnosis and Treatment of Essential Tremor

PURPOSE OF REVIEW: Essential tremor is a chronic, progressive syndrome that primarily presents with an action tremor involving the arms and hands. This article reviews the history and physical examination features pertinent for diagnosis, differential diagnoses, and treatments and approaches for optimal control of symptoms. RECENT FINDINGS: Essential tremor is a syndrome with symptoms extending beyond tremor to involve disturbances in gait, speech, cognition, and mood. Although the new guidelines on the definition and biaxial classification scheme have provided clarity, some tremor experts have critiqued the recently coined term essential tremor plus. For treatment, new orthotic devices and peripheral stimulation devices are now available in addition to pharmacologic and surgical options. SUMMARY: Essential tremor has a rich clinical phenomenology with many subtleties and nuances. A detailed history with open-ended questions and focused questions encompassing medical history, social history, and family history is key for establishing the diagnosis. The presence of bilateral action tremor for 3 years and absence of isolated head and voice tremor and absence of task- and position-dependent tremor are necessary for diagnosis. Dystonic tremor, Parkinson disease tremor, physiologic tremor, and drug-induced tremor are common differential diagnoses. Differentiating these tremor disorders from essential tremor based on phenomenology and physical examination alone could be challenging; thus, clinicians should seek additional clues from a detailed history. Treatment could begin with noninvasive and nonpharmacologic therapies, especially in mild cases. As the severity increases, they can advance stepwise to include pharmacotherapies and surgical interventions. With the growing recognition that essential tremor is not a monosymptomatic disorder, management should involve a multidisciplinary team. Furthermore, treatment selection should be based on shared decision making between patients and providers that gives due consideration to severity of symptoms, level of functional disability, impact on social interactions, patient preferences, and patient expectations.