Neurology · Year 3 · from Neurology
Case 2: Essential Tremor
Patient Demographics
- Age: 55 years
- Sex: Female
- Occupation: Elementary school teacher
Chief Complaint
"My hands shake when I try to write or drink from a cup."
History of Present Illness
The patient has had tremor in both hands for approximately 15 years. Unlike at rest, the tremor appears when she reaches for objects or performs tasks. She has difficulty writing on the board and has had to switch to using a projector. She cannot carry a full cup of coffee without spilling. The tremor briefly improves after drinking alcohol (which she discovered accidentally). Her father and grandmother both had similar tremors. The tremor has gradually worsened but has not affected her walking or cognition. She denies any other neurological symptoms.
Neurological Examination Findings
Mental Status:
- Alert, oriented, normal cognition
- Normal facial expression
Cranial Nerves:
- Mild head tremor (titubation) - "yes-yes" pattern
- No vocal tremor
- Otherwise intact
Motor Examination:
- Tremor:
- Bilateral hand tremor, 6-8 Hz
- Action tremor: Present during finger-to-nose testing (kinetic tremor)
- Postural tremor: Present when arms extended forward
- Minimal at rest - key distinguishing feature from Parkinson's
- Amplitude similar bilaterally
- Rigidity: None
- Bradykinesia: None - finger taps normal speed and amplitude
- Strength: 5/5 throughout
Writing Sample:
- Large, tremulous handwriting (compare to micrographia in PD)
- Spiral drawing shows significant tremor
Reflexes:
- 2+ symmetric
- Plantar responses flexor
Coordination:
- Finger-to-nose: Tremor increases as approaching target (intention component)
- Heel-to-shin: Mild tremor
- No dysmetria
Gait:
- Normal, no rigidity or bradykinesia
- Normal arm swing
- Tandem gait: Normal
Essential Tremor vs Parkinson's Disease
| Feature | This Patient (ET) | Parkinson's |
|---|---|---|
| Tremor type | Action/postural | Rest |
| Tremor frequency | 6-8 Hz | 4-5 Hz |
| Bilateral | Yes | Usually asymmetric at onset |
| Family history | Positive | Usually negative |
| Alcohol response | Improves | No effect |
| Bradykinesia | Absent | Present |
| Rigidity | Absent | Present |
| Handwriting | Large, tremulous | Micrographia |
Neuro Workup
- Clinical diagnosis - no imaging required
- Labs to exclude secondary causes:
- TSH: Normal (hyperthyroidism can cause tremor)
- Comprehensive metabolic panel: Normal
- DaTscan: Normal (would be abnormal in Parkinson's) - only if diagnostic uncertainty
Diagnosis
Essential Tremor - bilateral postural and kinetic tremor, positive family history, alcohol-responsive, no parkinsonian features
Management
Pharmacological Treatment:
- First-line: Propranolol 20-40 mg BID, titrate up to 120-320 mg/day
- Beta-blocker reduces tremor amplitude
- Avoid if asthma, bradycardia, heart block
- First-line alternative: Primidone 25 mg at bedtime, titrate to 250 mg TID
- Anticonvulsant with anti-tremor effect
- Start low due to sedation, ataxia
- Second-line: Topiramate, gabapentin, alprazolam
PRN/Situational Treatment:
- Propranolol 20-40 mg before important events
- Small amount of alcohol (patient declines)
Non-Pharmacological:
- Weighted utensils for eating
- Use two hands for cups
- Adaptive writing tools (weighted pen, keyboard)
- Avoid caffeine (may worsen)
Surgical Options (for refractory cases):
- Deep brain stimulation (VIM nucleus of thalamus)
- MRI-guided focused ultrasound thalamotomy
- Indicated if: Medication failure or intolerance, significant functional impairment
- Success rate: 70-90% tremor reduction
Clinical Image
Image Description: Archimedes spiral drawing demonstrating the tremulous line quality characteristic of essential tremor, with large amplitude fluctuations throughout the drawing.
Attribution: Image from Wikipedia Commons, public domain. Source: https://commons.wikimedia.org/wiki/File:Essential_tremor_spiral.jpg