⏱️ Onset & Time Course
- When did the tremor first appear?
- Was onset sudden (stroke, drug-related, metabolic) or gradual (essential tremor, Parkinson’s)?
- Is it progressive, static, or fluctuating?
🔍 Character of the Tremor
- Occurs at rest (suggests Parkinsonism), with posture, or during action/intention?
- Unilateral (early Parkinson’s, focal lesion) or bilateral (essential tremor)?
- Fine vs coarse; intermittent vs continuous?
- Which body parts are involved – hands, head, voice, jaw, legs?
⚡ Triggers & Modifiers
- Exacerbated by stress, anxiety, caffeine, fatigue, exercise?
- Improves with alcohol (classical for essential tremor)?
- Worse at rest or with movement?
🧩 Associated Neurological Symptoms
- Parkinsonian features: bradykinesia, rigidity, gait change, reduced arm swing.
- Cerebellar symptoms: ataxia, dysarthria, vertigo.
- Other red flags: weakness, sensory loss, seizures, cognitive decline.
💊 Medication & Substance History
- Drugs associated with tremor: lithium, valproate, SSRIs, antipsychotics, salbutamol.
- Alcohol intake, caffeine use, recreational drugs.
🧬 Family History
- Essential tremor (often autosomal dominant).
- Parkinson’s disease, dystonia, other movement disorders.

🩺 Physical Examination

👀 General Observation
- Observe at rest, with posture (arms outstretched), and during action.
- Note frequency, amplitude, symmetry and distribution.
🧠 Neurological Examination
- Parkinsonism: resting tremor, rigidity (cogwheel), bradykinesia.
- Cerebellar signs: intention tremor, dysmetria, nystagmus, broad-based gait.
- Motor strength, reflexes, sensation.
✋ Postural Tremor Testing
- Ask patient to extend arms and spread fingers.
- Look for fine, high-frequency tremor.
🎯 Intention Tremor Testing
- Finger–nose and heel–shin tests.
- Worsening near the target suggests cerebellar pathology.

🔎 Investigations (Targeted)

🧪 Blood Tests
- Thyroid function (hyperthyroidism).
- Electrolytes, calcium, magnesium.
- Liver and renal function if metabolic cause suspected.
🧠 Imaging
- MRI brain if focal signs, rapid progression, or atypical features.
📈 Electrophysiology
- EMG may help characterise tremor frequency and pattern.

🧠 Differential Diagnosis of Tremor

🧩 Cause	🔍 Key Clinical Features	💊 Management
Essential Tremor	• Bilateral, symmetrical • Action/postural tremor • Hands, head, voice • Improves with alcohol • No other neurological signs	• Propranolol • Primidone • DBS if refractory
Parkinsonian Tremor	• Resting “pill-rolling” tremor • Unilateral onset • Bradykinesia, rigidity • Improves with movement	• Levodopa • Dopamine agonists • Physiotherapy
Cerebellar Tremor	• Intention tremor • Dysmetria, ataxia • Dysarthria, nystagmus	• Treat underlying cause • Physiotherapy • Clonazepam/propranolol (limited benefit)
Physiological Tremor	• Fine, fast, low-amplitude • Exacerbated by stress, caffeine, fatigue	• Reassurance • Avoid triggers
Drug-Induced Tremor	• Temporal relation to medication • Often bilateral	• Reduce/stop offending drug • Alternative therapy
Dystonic Tremor	• Irregular tremor • Abnormal postures • Improves with sensory tricks	• Botulinum toxin • Anticholinergics • OT/physiotherapy

💊 Management Principles

🎯 Treat the underlying cause (metabolic, drug-induced, endocrine).
💉 Pharmacological therapy tailored to tremor type.
🧑‍⚕️ Non-pharmacological: physiotherapy, occupational therapy.
🧠 Surgical options: DBS for severe, refractory essential or Parkinsonian tremor.

📚 Key Teaching Pearls

🧠 Rest vs action tremor is the most important first discriminator.
🍷 Alcohol improvement strongly suggests essential tremor.
⚠️ Sudden onset tremor → think stroke, drugs, metabolic causes.
🔍 Tremor rarely exists in isolation — always examine gait and tone.

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Causes of Tremor

🧠 History Taking (Structured & High-Yield)

🩺 Physical Examination

🔎 Investigations (Targeted)

🧠 Differential Diagnosis of Tremor

💊 Management Principles

📚 Key Teaching Pearls

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