Table 5

Features differentiating essential tremor from other disorders

DiagnosisTremor typeFrequencyUnilateral/bilateralAreas involvedAlcohol responsive?Other features
Essential tremorPostural, intention4–12 HzUsually bilateralHands, head, legs, voice, face (jaw), neck and trunkCommonly (50–90% of patients)May have mild cerebellar signs and eye movement abnormalities
Enhanced physiologicalPostural, intention8–12 HzBilateralHandsMaybeUsually associated with stress, caffeine, medications
Parkinson’s diseaseRest3–6 HzUsually starts unilateralHands, feet, lips (head is seldom involved)NoBradykinesia, rigidity, postural instability
CerebellarIntention, postural<5 HzUnilateral or bilateral (depending on which side cerebellum is affected)Usually head/upper part of the bodyNoOther findings of cerebellar dysfunction
DystoniaPostural<7 HzBilateralHeadUsually no—alcohol may make symptoms worseSensory trick
PsychogenicRest and/or postural (intermittent, can change in frequency or amplitude)4–12 HzUnilateral or bilateralArms, legs, headNoUsually sudden onset; exhausting for patients Distractable, co-activation sign
Orthostatic tremorPostural13–18 HzBilateralUsually legs, can occur in arms and trunk as wellNoAuscultation by stethoscope
Wilson’s diseasePostural, intention “wing beating”4–6 HzBilateralArms, legs, trunkNoOther associated findings: liver disease, incoordination, dysarthria, dystonia, spasticity, Kayser–Fleisher rings
Task specific tremorTask-specific4–8 HzUnilateralHandsNoTasks may include writing, playing a musical instrument, playing sports, etc
Holmes’ s tremor (“rubral tremor”)Rest, postural, intention2–5 HzUnilateral or bilateral depending on location of lesionArms, trunkNoAssociated cerebellar signs (red nucleus). Usually occurs 4 weeks to 2 years after lesion
Neuropathic tremorPostural, intention3–6 HzBilateralArms, legs (where neuropathy is present)NoAssociated with an underlying neuropathy, demyelinating most common
Fragile X-associated tremor/ataxia syndrome (FXTAS)Intention most common (activated by writing). Can see mixture of intention and rest or rest alone3–5 HzUnilateral or bilateralArmsNoMales >50 years old with tremor, ataxia, cognitive and behavioural problems. Fragile X-mental retardation 1 (FMR 1) gene premutation. Maternal inheritance. Family history of mental retardation