Approach to Tremor

Differential diagnosis

• Endocrine
  • Hyperthyroidism
  • Phaeochromocytoma
  • Hypoglycaemia
• Neurological
  • Parkinsonism
  • Cerebellar disease
• Drugs
  • Caffeine
  • Salbutamol
  • Theophylline
  • Phenytoin
  • Lithium
  • Cyclosporine and tacrolimus
  • Alcohol (including alcohol withdrawal)
  • Illicit drugs (including drug withdrawal)
• Wilson’s disease
• Essential tremor
• Psychological

Relevant points in the history

• Tremor
  • When did you first notice it?
  • Is in in one hand or both?
  • Is it worse at rest or when you try to do something?
  • Does anything make it better?
  • Does anything make it worse?

Examination

• Parkinsonism
  • Bradykinesia
  • Rigidity
  • Cogwheeling
  • Gait
  • Hypophonia
• Cerebellar
  • Nystagmus
  • Intention tremor
  • Dysmetria
  • Dysdiadochokinesis
  • Staccato speech
• Hyperthyroidism
  • Pulse
  • Ophthalmopathy
  • Lid lag
  • Goitre
  • Thyrocardiac disease
  • Pre-tibial myxoedema

Investigations

• Full blood count, renal function and liver function if on drugs which may cause tremor
• Cyclosporine / tacrolimus levels as tremor may be dose-dependent
• Thyroid function tests
• Blood sugar level (hypoglycaemia)
• Consider plasma metanephrines if history suggestive of phaeochromocytoma
• Consider magnetic resonance imaging of the brain if Parkinsonism present to rule out CVA, SOC

Management

• Multidisciplinary
• Patient education – e.g. avoid using laser pointers, computer mice
• Occupational therapy for adjuncts, e.g. wrist weights
• Withdrawal of offending drug
• Essential tremor
  • Propranolol (40 – 240mg/day) or primidone (anticonvulsant) as a first line
  • May combine both if either not effective
• Parkinsonism
  • Consider anti-cholinergics for tremor-predominant PD
  • Levodopa may improve other symptoms