Almost everyone who comes in with a tremor arrives carrying the same unspoken question, so this page answers it first and works outward from there.
Is my tremor Parkinson's?
Usually not. The single most useful thing to notice is when your hands shake. Essential tremor shows up when they are doing something: bringing a spoon to your mouth, signing your name, holding a phone steady. Parkinsonian tremor classically appears when the hand is resting in your lap and quiets as soon as you reach for something. The line is not absolute, though. In long-standing or severe essential tremor a rest component can appear too, and a Parkinson's tremor can re-emerge after holding the arms out for several seconds.
| Essential tremor | Parkinson's tremor | |
|---|---|---|
| When it appears | While the hands are in action: holding, writing, pouring | While the hand rests, quieting when you reach for something |
| Which side | Usually both hands, roughly equally | Usually starts on one side and stays worse there |
| What comes with it | Sometimes a head nod or a quaver in the voice | Slowness, stiffness, smaller handwriting, reduced arm swing |
| Family history | Common | Less common |
| Effect of alcohol | Often briefly better | No characteristic change |
A neurologist watching you write, pour water, and hold your arms outstretched can usually make this distinction in one visit. When the picture is genuinely ambiguous, a DaTscan can settle it, but most patients never need one.
What essential tremor is
Essential tremor is a common, frequently inherited condition in which the brain's movement circuits generate a rhythmic tremor during action, usually in both hands and sometimes in the head or voice. It worsens slowly over years. It also, notoriously, eases for a short time after alcohol, which is a diagnostic clue rather than a treatment plan.
It is benign in the medical sense, meaning it does not shorten life. There is nothing benign about being unable to eat soup in public, sign documents, or do your job, and that impact is the treatment threshold. No rating scale decides it for you.
Visual guide
When action brings out a tremor
- Holding: A tremor may appear while holding a cup.
- Writing: Fine hand movements can become difficult.
- Impact: Treatment depends on how symptoms affect daily life.
Other tremors worth naming
Not every shaky hand is essential tremor, and each of these is treated differently.
| Tremor | What points to it | Why it matters |
|---|---|---|
| Enhanced physiologic tremor | Caffeine, thyroid overactivity, low blood sugar, or a new medication | Often resolves completely once the cause is removed |
| Dystonic tremor | Abnormal posturing of the affected hand or neck | Responds to different treatment than essential tremor |
| Functional tremor | Changes or stops with distraction, and varies in rhythm | Improves with a specific physical therapy, not with tremor medication |
| Cerebellar tremor | Worsens as the hand approaches a target | Points to the cerebellum, sometimes multiple sclerosis |
Because each of these calls for a different treatment, and one of them needs no medication at all, the diagnosis has to come before the prescription.
What makes tremor worse
Essential tremor is not constant. It rises and falls with things you can sometimes change, and knowing them explains a lot of bad days.
- Stress, anxiety, and being watched. Adrenaline amplifies any tremor, which is why it is worst at the moment you most want steady hands, and why it can feel as if it has a mind of its own.
- Caffeine, nicotine, and poor sleep all turn the volume up.
- Medications. Some asthma inhalers, corticosteroids, certain antidepressants, lithium, valproate, thyroid hormone at too high a dose, caffeine, stimulants, amiodarone, and some transplant medicines can all bring out or worsen action tremor. Dopamine-blocking anti-nausea drugs such as metoclopramide cause a different problem, a Parkinson-like rest tremor with slowness. Do not stop a prescribed medication on your own; bring the list and we look at it together.
- Thyroid overactivity and low blood sugar are the two medical causes worth checking with a blood test.
- Cold, fatigue, and hunger make it more visible.
How tremor is treated
Treatment is stepped, and matched to how much the tremor is costing you. Many people with mild essential tremor choose no treatment at all once they know what it is and what it is not.
- Medication. Propranolol and primidone remain the standard starting points your neurologist will discuss. An honest expectation is that they reduce tremor rather than remove it, they help many patients and not all, and alternatives exist when they do not suit you. Side effects and the plan for adjusting the dose are set at the visit and revisited at follow-up.
- Situational strategies. Some people ask whether medication can be timed around a presentation, a signing, or a meal out. That is a reasonable question to raise with your neurologist, who can say whether it fits your medication. Weighted utensils and pens, and treating the anxiety loop, since tremor worsens with stress and visible tremor creates stress, help alongside.
- Botulinum toxin injections. Head and voice tremor often respond less well to tablets than hand tremor does. Propranolol can help head tremor. Botulinum toxin injections, arranged with a colleague, are rated by the AAN as possibly effective, at the cost of neck weakness for head tremor or a breathy voice and swallowing difficulty for voice tremor. We do not perform these injections in our office. When they are the right option we say so and refer you to a colleague who does.
- Advanced options. For severe, medication-resistant tremor, MRI-guided focused ultrasound and deep brain stimulation can produce dramatic improvement. Both are done at specialized centers, and we help you decide whether a referral makes sense and coordinate the evaluation.
What a tremor evaluation involves
A first visit is 60 minutes and is done in person at our Beverly Hills or Los Angeles office, because the examination is what makes the diagnosis. We take a detailed history: when the tremor started, what brings it out, whether anyone in your family has it, what you drink and what you take. Then we examine you, watching the hands at rest and in action, drawing spirals and writing, pouring water, checking muscle tone and speed of movement, and watching you walk.
Blood tests for thyroid function and other reversible causes are usually ordered. Imaging is not routine. A DaTscan is reserved for the minority of cases where the examination cannot separate essential tremor from Parkinson's disease, and an MRI only when the examination points somewhere else. You leave with a working diagnosis and a written plan, and follow-up can usually be done by video.
Visual guide
Describing a tremor clearly
- Timing: Tremor at rest and tremor during action are described.
- Context: Medications and factors that worsen it are reviewed.
- Function: Writing, pouring, and other tasks show its practical effect.
When to see a neurologist
When the tremor is new, when it is changing, when one side clearly leads, or when it has begun costing you things: handwriting, meals out, confidence at work. And if the quiet fear of Parkinson's is following you around either way, one careful examination usually replaces months of worry with an actual answer. Dr. Achillefs Ntranos, MD is a board-certified neurologist and sees every patient himself; you can request a visit in Beverly Hills or Los Angeles, with no referral needed.
Frequently asked questions
References
- National Institute of Neurological Disorders and Stroke. Tremor.
- Cleveland Clinic. Essential Tremor.
- Bhatia KP, et al. Consensus Statement on the classification of tremors, from the task force on tremor of the International Parkinson and Movement Disorder Society. Movement Disorders, 2018.
- Zesiewicz TA, et al. Evidence-based guideline update: treatment of essential tremor. Neurology, 2011.
- Zesiewicz TA, et al. Practice parameter: therapies for essential tremor. Neurology, 2005.
- MedlinePlus Medical Encyclopedia. Drug-induced tremor. National Library of Medicine.
- Baizabal-Carvallo JF, et al. Drug-induced tremor, clinical features, diagnostic approach and management. Journal of the Neurological Sciences, 2022.
- Cohen O, et al. Rest tremor in patients with essential tremor: prevalence, clinical correlates, and electrophysiologic characteristics. Archives of Neurology, 2003.
- Delgado N, et al. Distribution of rest tremor in patients with essential tremor. Parkinsonism and Related Disorders, 2022.