Essential Tremor¶

DIAGNOSIS: Essential Tremor ICD-10: G25.0 (Essential tremor) SCOPE: Diagnosis confirmation, differentiation from Parkinson's disease and other tremors, and symptomatic treatment. Covers classic essential tremor and ET-plus syndrome.

STATUS: Draft - Pending Review

PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

SECTION A: ACTION ITEMS¶

1. LABORATORY WORKUP¶

1A. Essential/Core Labs¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
TSH	Hyperthyroidism causes action tremor	Normal (0.4-4.0 mIU/L)	URGENT	ROUTINE	ROUTINE	-
Free T4	If TSH abnormal	Normal	URGENT	ROUTINE	ROUTINE	-
BMP	Electrolyte abnormalities (hypomagnesemia) can cause tremor	Normal	STAT	ROUTINE	ROUTINE	-
Glucose	Hypoglycemia causes tremor	70-180 mg/dL	STAT	ROUTINE	-	-
Hepatic panel	Hepatic encephalopathy can cause asterixis/tremor; baseline before medications	Normal	-	ROUTINE	ROUTINE	-

1B. Extended Workup (Second-line)¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
Magnesium	Hypomagnesemia causes tremor	1.8-2.4 mg/dL	-	ROUTINE	ROUTINE	-
Ceruloplasmin, serum copper	Wilson's disease if age <50	Normal	-	EXT	ROUTINE	-
24-hour urine copper	Wilson's confirmation	<100 μg/24hr	-	-	EXT	-
Drug/toxin screen	Caffeine, stimulants, alcohol withdrawal	Negative or explains tremor	STAT	ROUTINE	EXT	-
Vitamin B12	Deficiency can cause tremor	>300 pg/mL	-	ROUTINE	ROUTINE	-

1C. Rare/Specialized (Refractory or Atypical)¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
Heavy metal panel (mercury, lead, arsenic)	Occupational exposure; toxin-induced tremor	Normal	-	-	EXT	-
Paraneoplastic antibody panel	Atypical tremor; occult malignancy	Negative	-	-	EXT	-
Anti-GAD65 antibodies	Stiff-person spectrum; autoimmune etiology	Negative	-	-	EXT	-
Genetic testing (LINGO1, SLC1A2)	Research; strong family history	Variable	-	-	EXT	-

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential/First-line¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
Clinical examination (spiral drawing, water pouring)	At evaluation	Symmetric action tremor; improves with alcohol; family history	None	STAT	ROUTINE	ROUTINE	-

2B. Extended¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
MRI Brain	Atypical features; focal signs; concern for structural lesion	Normal	MRI-incompatible devices	URGENT	ROUTINE	ROUTINE	-
DaTscan (ioflupane I-123)	Differentiate ET from Parkinson's disease	NORMAL in ET (abnormal in PD)	Iodine hypersensitivity	-	-	ROUTINE	-
EMG with accelerometry	Characterize tremor frequency (8-12 Hz typical ET)	4-12 Hz, predominantly postural/kinetic	None	-	-	EXT	-

2C. Rare/Specialized¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
MRI Brain with SWI	Wilson's disease evaluation; iron deposition	No basal ganglia abnormalities	MRI contraindications	-	EXT	EXT	-
PET scan	Research; rule out neurodegenerative parkinsonian syndromes	Normal nigrostriatal pathway	None	-	-	EXT	-
Slit lamp examination	Wilson's disease (Kayser-Fleischer rings)	No KF rings	None	-	EXT	EXT	-

3. TREATMENT¶

3A. Acute/Emergent¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Propranolol (as needed)	PO	Situational tremor (performance anxiety, important meeting)	20 mg PO; 40 mg PO :: PO :: :: 20-40 mg PO 30-60 min before anxiety-provoking situation; single dose PRN	Asthma; severe bradycardia; decompensated HF	HR, BP if first dose	URGENT	URGENT	ROUTINE	-

3B. Symptomatic Treatments (First-line)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Propranolol	PO	First-line chronic therapy; most evidence	20 mg BID; 40 mg BID; 60 mg BID; 80 mg BID; 120 mg daily LA; 160 mg daily LA :: PO :: :: Start 20 mg BID or 60 mg LA daily; titrate q2wk; target 60-240 mg/day	Asthma/COPD; bradycardia <50; heart block; decompensated HF	HR (>50 bpm), BP, fatigue, depression	-	ROUTINE	ROUTINE	-
Propranolol LA	PO	Once daily option for adherence	60 mg daily; 80 mg daily; 120 mg daily; 160 mg daily :: PO :: :: Start 60-80 mg daily; titrate q2wk; max 320 mg/day	Same as IR	Same as IR	-	ROUTINE	ROUTINE	-
Primidone	PO	First-line; equal efficacy to propranolol	25 mg qHS; 50 mg qHS; 50 mg TID; 125 mg TID; 250 mg TID :: PO :: :: Start 25 mg qHS (VERY LOW to avoid acute toxicity); increase by 25-50 mg q1wk; target 250-750 mg/day divided	Porphyria; severe hepatic impairment	Sedation (especially initial), ataxia, GI upset	-	ROUTINE	ROUTINE	-
Propranolol + Primidone	PO	Combination for better efficacy than monotherapy	Per individual drug :: PO :: :: Add second agent if monotherapy insufficient; use lower doses of each	Per individual drug	Monitor both sets of side effects	-	ROUTINE	ROUTINE	-

3C. Second-line/Refractory¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Topiramate	PO	Beta-blocker contraindicated; weight concern	25 mg qHS; 50 mg BID; 100 mg BID :: PO :: :: Start 25 mg qHS; increase by 25 mg q1wk; target 100-400 mg/day divided	Glaucoma; kidney stones; pregnancy	Cognitive effects, paresthesias, weight loss, metabolic acidosis	-	ROUTINE	ROUTINE	-
Gabapentin	PO	Mild benefit; good tolerability; neuropathic pain comorbidity	300 mg qHS; 300 mg TID; 600 mg TID; 900 mg TID :: PO :: :: Start 300 mg qHS; titrate by 300 mg q3-7d; target 1200-3600 mg/day divided TID	Severe renal impairment (dose adjust)	Sedation, dizziness, edema	-	ROUTINE	ROUTINE	-
Alprazolam	PO	Anxiolytic benefit; use with caution	0.25 mg TID; 0.5 mg TID :: PO :: :: Start 0.25 mg TID; titrate slowly; max 3 mg/day; avoid long-term if possible	Respiratory depression; history of substance use	Dependence, sedation, falls	-	ROUTINE	ROUTINE	-
Clonazepam	PO	Orthostatic tremor; head tremor; refractory cases	0.25 mg BID; 0.5 mg BID; 1 mg BID :: PO :: :: Start 0.25 mg BID; titrate slowly; typical 0.5-2 mg/day	Same as alprazolam	Same as alprazolam	-	ROUTINE	ROUTINE	-
Atenolol	PO	Beta-blocker alternative (more beta-1 selective)	25 mg daily; 50 mg daily; 100 mg daily :: PO :: :: Start 25-50 mg daily; max 100 mg daily	Heart block; severe bradycardia	HR, BP	-	ROUTINE	ROUTINE	-
Nadolol	PO	Long-acting beta-blocker alternative	40 mg daily; 80 mg daily; 120 mg daily :: PO :: :: Start 40 mg daily; titrate q1-2wk; max 240 mg daily	Same as propranolol	Same as propranolol	-	ROUTINE	ROUTINE	-
Sotalol	PO	Beta-blocker with additional antiarrhythmic properties	80 mg BID; 120 mg BID :: PO :: :: Start 80 mg BID; max 240 mg/day; requires QTc monitoring	QT prolongation; severe renal impairment	QTc, electrolytes	-	ROUTINE	ROUTINE	-
Nimodipine	PO	Limited evidence; calcium channel blocker	30 mg TID :: PO :: :: 30 mg TID	Hypotension	BP	-	-	EXT	-
Zonisamide	PO	Limited evidence; weight neutral	100 mg daily; 200 mg daily :: PO :: :: Start 100 mg daily; may increase to 200 mg daily	Sulfonamide allergy; renal stones	Kidney stones, rash	-	-	EXT	-

3D. Interventional/Advanced Therapies¶

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Botulinum toxin (head tremor)	IM	Head/neck tremor refractory to oral medications	100-200 units total :: IM :: :: Inject into sternocleidomastoid and splenius capitis bilaterally; repeat q3-4mo	EMG guidance recommended	Infection at site; myasthenia gravis	Dysphagia, neck weakness	-	-	ROUTINE	-
Botulinum toxin (hand tremor)	IM	Hand tremor refractory to oral medications	50-100 units per hand :: IM :: :: Inject into forearm flexors/extensors; EMG-guided; repeat q3mo	EMG guidance required	Same as above	Finger weakness (limits use)	-	-	ROUTINE	-
Deep brain stimulation (DBS)	Surgical	Medication-refractory disabling tremor	VIM thalamus stimulation :: Surgical :: :: Unilateral or bilateral VIM thalamus; programming over weeks	MRI; neuropsych testing; multidisciplinary evaluation	Cognitive impairment; unstable psychiatric disease; coagulopathy	Programming optimization; speech side effects (bilateral)	-	-	ROUTINE	-
MRI-guided focused ultrasound (MRgFUS)	Non-invasive	Unilateral tremor; DBS declined or contraindicated	VIM thalamotomy :: Non-invasive :: :: Unilateral lesion of VIM thalamus; immediate effect	Must tolerate prolonged MRI	Bilateral procedure not recommended (speech risk); skull density ratio	Numbness, ataxia, speech changes (usually transient)	-	-	ROUTINE	-
Gamma Knife radiosurgery	Non-invasive	VIM thalamotomy; DBS contraindicated	130-150 Gy to VIM :: Non-invasive :: :: Unilateral lesion; delayed effect (months)	MRI compatible	Same as MRgFUS	Same as MRgFUS; delayed effect	-	-	EXT	-

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	ED	HOSP	OPD	ICU
Movement disorders neurology for diagnosis confirmation if uncertain and treatment optimization	-	ROUTINE	ROUTINE	-
Neurosurgery consultation for DBS or MRgFUS evaluation if medication-refractory	-	-	ROUTINE	-
Occupational therapy for adaptive devices and hand-writing strategies	-	-	ROUTINE	-
Physical therapy for postural training and coordination exercises	-	-	ROUTINE	-
Psychology/counseling for anxiety management and coping strategies	-	-	ROUTINE	-

4B. Patient Instructions¶

Recommendation	ED	HOSP	OPD
Avoid or minimize caffeine which can worsen tremor	-	ROUTINE	ROUTINE
Limit alcohol (may temporarily improve tremor but rebound worsening occurs and dependence risk)	-	ROUTINE	ROUTINE
Get adequate sleep as fatigue worsens tremor	-	ROUTINE	ROUTINE
Manage stress and anxiety which exacerbate tremor (relaxation techniques, regular exercise)	-	ROUTINE	ROUTINE
Use weighted utensils and adaptive devices for eating and writing if tremor interferes	-	ROUTINE	ROUTINE
Report any new symptoms such as slowness, stiffness, or balance problems which may indicate progression to ET-plus or Parkinson's	-	ROUTINE	ROUTINE
Consider alerting employer/school if tremor affects work performance to discuss accommodations	-	-	ROUTINE

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD
Regular physical exercise improves overall motor function and stress management	-	ROUTINE	ROUTINE
Relaxation techniques (yoga, meditation, deep breathing) reduce stress-related tremor exacerbation	-	-	ROUTINE
Avoid medications that worsen tremor (lithium, valproate, some antidepressants, stimulants) when alternatives exist	-	ROUTINE	ROUTINE
Use larger-grip pens and utensils to improve function	-	-	ROUTINE
Voice-to-text software if writing is significantly impaired	-	-	ROUTINE
Limit alcohol despite temporary improvement to avoid dependence and rebound tremor	-	ROUTINE	ROUTINE

SECTION B: REFERENCE¶

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Parkinson's disease	Rest tremor predominant; bradykinesia; rigidity; asymmetric onset	DaTscan (abnormal in PD, normal in ET); clinical exam
Enhanced physiologic tremor	Typically bilateral, postural; related to caffeine, anxiety, medications, hyperthyroidism	Remove triggers; check TSH, caffeine history
Drug-induced tremor	Temporal relationship with medication; bilateral	Medication review; trial withdrawal
Dystonic tremor	Irregular, jerky; task-specific; associated dystonic posturing; null point	Clinical exam; may see dystonia at rest
Cerebellar tremor	Intention tremor (worsens at target); associated ataxia, dysarthria	MRI brain (cerebellar pathology); clinical exam
Psychogenic tremor	Variable frequency; distractible; entrainment with contralateral movement	Clinical maneuvers; psychiatric evaluation
Wilson's disease	Age <50; liver disease; psychiatric symptoms; Kayser-Fleischer rings	Ceruloplasmin, 24h urine copper, slit lamp
Orthostatic tremor	Tremor in legs/trunk when standing; relief with sitting/walking	EMG (13-18 Hz characteristic)
Rubral tremor	Rest + postural + intention ("Holmes tremor"); midbrain lesion history	MRI (midbrain pathology)
Neuropathic tremor	Associated with peripheral neuropathy (CIDP, IgM paraprotein)	EMG/NCS; protein electrophoresis

6. MONITORING PARAMETERS¶

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
Tremor severity (clinical rating scales: Fahn-Tolosa-Marin, TETRAS)	Each visit	50%+ improvement with treatment	Adjust medication dose; consider second agent or intervention	-	ROUTINE	ROUTINE	-
Functional impact (writing, eating, drinking)	Each visit	Acceptable function for patient	OT referral; adaptive devices; consider advanced therapy	-	ROUTINE	ROUTINE	-
Heart rate (if on beta-blocker)	Each visit	>50 bpm	Reduce dose or switch agent	-	ROUTINE	ROUTINE	-
Blood pressure (if on beta-blocker)	Each visit	>90/60	Reduce dose or switch agent	-	ROUTINE	ROUTINE	-
Sedation/cognition (if on primidone or benzodiazepines)	Each visit	Tolerable side effects	Reduce dose; slow titration	-	ROUTINE	ROUTINE	-
Signs of parkinsonism	Each visit	No bradykinesia, rigidity, rest tremor	Re-evaluate diagnosis; DaTscan if uncertain	-	ROUTINE	ROUTINE	-
Weight (if on topiramate)	Every 3 months	Stable or acceptable change	Adjust dose	-	-	ROUTINE	-
QTc (if on sotalol)	Baseline, with dose changes	<500 msec	Reduce dose or discontinue	-	ROUTINE	ROUTINE	-

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Discharge home	New diagnosis with treatment started; follow-up arranged; no red flags
Admit to floor	Rare; only if tremor is severe and workup needed urgently (e.g., Wilson's disease suspected)
Outpatient follow-up	4-8 weeks for medication titration; then every 6-12 months when stable

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
Propranolol first-line for ET	Class I, Level A	Zesiewicz et al. Neurology 2011 (AAN Guideline)
Primidone first-line for ET	Class I, Level A	Zesiewicz et al. Neurology 2011
Topiramate effective for ET	Class II, Level B	Ondo et al. Neurology 2006
DBS effective for medication-refractory ET	Class I, Level A	Flora et al. Cochrane 2010
MRI-guided focused ultrasound for ET	Class I, Level A	Elias et al. NEJM 2016
DaTscan differentiates ET from PD	Class II, Level B	Benamer et al. Mov Disord 2000
Botulinum toxin for head tremor	Class II, Level B	Pahwa et al. Neurology 1995
Gabapentin modest benefit	Class II, Level U	Ondo et al. Neurology 2000
Combination therapy superior to monotherapy	Class II, Level B	Koller et al. Neurology 1989

CHANGE LOG¶

v1.0 (January 27, 2026) - Initial template creation - Comprehensive medication coverage including first and second-line options - Includes advanced interventions (DBS, MRgFUS, Gamma Knife) - Structured dosing format for order sentence generation