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Diagnosis and Management of Tremor

Louis, Elan D. MD, MS, FAAN

doi: 10.1212/CON.0000000000000346
Review Articles

ABSTRACT Purpose of Review: Tremor, which is a rhythmic oscillation of a body part, is among the most common involuntary movements. Rhythmic oscillations may manifest in a variety of ways; as a result, a rich clinical phenomenology surrounds tremor. For this reason, diagnosing tremor disorders can be particularly challenging. The aim of this article is to provide the reader with a straightforward approach to the diagnosis and management of patients with tremor.

Recent Findings: Scientific understanding of the pathophysiologic basis of tremor disorders has grown considerably in recent years with the use of a broad range of neuroimaging approaches and rigorous, controlled postmortem studies. The basal ganglia and cerebellum are structures that seem to play a prominent role.

Summary: The diagnosis of tremor disorders is challenging. The approach to tremor involves a history and a neurologic examination that is focused on the nuances of tremor phenomenology, of which there are many. The evaluation should begin with a tremor history and a focused neurologic examination. The examination should attend to the many subtleties of tremor phenomenology. Among other things, the history and examination are used to establish whether the main type of tremor is an action tremor (ie, postural, kinetic, or intention tremor) or a resting tremor. The clinician should then formulate two sets of differential diagnoses: disorders in which action tremor is the predominant tremor versus those in which resting tremor is the main tremor. Among the most common of the former type are essential tremor, enhanced physiologic tremor, drug-induced tremor, dystonic tremor, orthostatic tremor, and cerebellar tremor. Parkinson disease is the most common form of resting tremor, along with drug-induced resting tremor. This article details the clinical features of each of these as well as other tremor disorders.

Address correspondence to Dr Elan D. Louis, Yale School of Medicine, Department of Neurology, LCI 710, 15 York St, PO Box 20818, New Haven, CT 06520-8018, elan.louis@yale.edu.

Relationship Disclosure: Dr Louis reports no disclosure.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Louis discusses the unlabeled/investigational use of acetazolamide, alprazolam, baclofen, carbamazepine, clonazepam, cyclophosphamide, ethosuximide, gabapentin, phenobarbital, phenytoin, pregabalin, primidone, and topiramate for the treatment of tremor as well as carbidopa/levodopa for the treatment of orthostatic tremor and trihexyphenidyl for the treatment of dystonic tremor.

Supplemental digital content: Videos accompanying this article are cited in the text as Supplemental Digital Content. Videos may be accessed by clicking on links provided in the HTML, PDF, and app versions of this article; the URLs are provided in the print version. Video legends begin on page 1155.

© 2016 American Academy of Neurology
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