Essential Tremor (ET) is one of the most common movement disorders, often inherited in an autosomal dominant pattern. It is benign in terms of survival 🕊️, but can be socially and functionally disabling. 👉 Many patients worry about Parkinson’s Disease (PD), making differentiation crucial in clinical practice.

🧑‍⚕️ Clinical Features

Presentation: Gradual onset of a 4–12 Hz postural/action tremor, typically in the hands and forearms. ✋
Head Tremor (Titubation): "Yes–yes" or "no–no" rhythmic nodding movements. May also affect the voice 🎤.
Voice Tremor: Can produce a quavering, shaky voice quality.
Leg Tremor: Rare but possible.
Cogwheeling: May be present, but without true rigidity.
Course: Symmetrical, slow progression over years; gait usually normal.

🔍 Differentiation from Parkinson’s Disease (PD)

Key distinctions between ET and PD:

⏳ ET: Postural/action tremor; usually bilateral and improves with alcohol 🍷. PD: Resting tremor ("pill-rolling"), asymmetrical, no alcohol benefit.
🚶 ET: Normal gait & no bradykinesia. PD: Bradykinesia, shuffling gait, reduced arm swing.
🧾 ET: Family history common (autosomal dominant). PD: Usually sporadic, though some genetic forms exist.
👀 Head/voice tremor: Common in ET, rare in PD.

🧪 Investigations

Clinical Diagnosis: ET is largely a bedside diagnosis.
18F-FDOPA PET: Helps distinguish ET (normal uptake) vs PD (reduced striatal uptake). 🎯
Thyroid Function Tests (TFTs): Exclude hyperthyroidism, which may mimic tremor.
Wilson’s Disease Screening: In patients <40 yrs with tremor → check caeruloplasmin, serum & urine copper 🧪.

📋 Differential Diagnosis

Anxiety & Stress Tremor: Often situational, transient.
Parkinson’s Disease: Distinguished by rest tremor, rigidity, and bradykinesia.
Wilson’s Disease: Younger patients, "wing-beating" tremor + other neuro signs.

💊 Management

Reassurance: Many patients feel relieved once PD is excluded. 🧾
Lifestyle: Minimise caffeine, stress; small amounts of alcohol may transiently help but not a long-term therapy.
Medications:
- 🫀 Propranolol (β-blocker): First-line; reduces tremor amplitude.
- 💊 Primidone (anticonvulsant): Useful if propranolol not tolerated.
- 😊 Mirtazapine: Consider if anxiety/depression co-exist.
Advanced therapy: Severe, refractory cases → stereotactic thalamotomy or Deep Brain Stimulation (DBS). ⚡

💡 Exam Pearls

• ET = action tremor, symmetrical, family history, improves with alcohol. • PD = resting tremor, asymmetrical, bradykinesia, rigidity, no alcohol benefit. • Severe ET → consider DBS of the ventral intermediate nucleus (VIM) of the thalamus.

📚 References

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Essential Tremor