Overview
This podcast episode features Dr. Binit Shah discussing essential tremor, highlighting its diagnosis, key clinical features, differential diagnosis, and current management options, including therapy, medications, and surgical interventions.
Diagnosis and Clinical Features of Tremor
- Essential tremor is determined primarily through clinical evaluation rather than paraclinical testing.
- Important history elements: onset, course, exacerbating/alleviating factors, and tremor characteristics (amplitude, frequency, phase of movement).
- Essential tremor presents as an action tremor with gradual onset, often with a frequency between 8-12 Hz and amplitude greater than minimal.
- Family history may be present but is not required; essential tremor can be sporadic or familial.
- Alcohol may suppress tremor in some but not all patients.
Differential Diagnosis and Exam Considerations
- Differential includes Parkinson’s tremor (resting), cerebellar tremor, dystonic tremor, medication-induced tremor, and comorbidities.
- Neurological examination is important; additional symptoms like asymmetry or coordination deficits may warrant imaging.
- Dystonic tremor tends to be jerkier and may involve abnormal joint posturing, often starts in the head.
Treatment Approaches for Essential Tremor
- Treatment is driven by symptom burden and impact on daily/professional activities.
- Non-pharmacologic treatments: occupational therapy can help patients maintain activities without drugs.
- First-line medications: propranolol (contraindicated in asthma/COPD, caution in diabetes, depression, cardiac issues) and primidone (tolerability issues, can interact with certain anticoagulants).
- Second-line agents: topiramate, zonisamide, and gabapentin.
- Botulinum toxin may be considered for focal tremor, though balancing tremor reduction with muscle weakness and insurance coverage are challenges.
Surgical Interventions
- Indicated for severe, disabling tremor unresponsive to conservative management.
- Deep brain stimulation (DBS): electrode implantation in VIM nucleus; adjustable and can be bilateral.
- MRI-guided focused ultrasound thalamotomy: non-incisional, creates a controlled lesion; may be preferred if anesthesia risk is high or for unilateral tremor.
- Both approaches offer 50-80% contralateral tremor reduction; adverse effects differ (DBS: infection risk, hardware issues; ultrasound: imbalance, ataxia, sensory changes).
- Surgical choice often depends on patient preference, tremor laterality, and anesthesia risk.
Emerging Therapies and Future Directions
- New pharmacologic therapies are in development, with efficacy compared to existing agents yet to be established.
Recommendations / Advice
- Comprehensive neurological examination and detailed history are essential for accurate tremor diagnosis.
- Individualize treatment based on symptom severity, patient comorbidities, and preferences.
- Consider occupational therapy and non-pharmacologic approaches before medications or surgery.
- For medication selection, assess contraindications and potential adverse effects specific to each patient.
- Reassure patients if Parkinson’s disease is not present based on exam findings.