Essential Tremor

VERSION: 1.0 CREATED: January 29, 2026 REVISED: January 29, 2026 STATUS: Approved

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DIAGNOSIS: Essential Tremor

ICD-10: G25.0 (Essential tremor), G25.1 (Drug-induced tremor), G25.2 (Other specified forms of tremor), G25.9 (Extrapyramidal and movement disorder, unspecified)

CPT CODES: 84443 (TSH), 84439 (Free T4), 80053 (CMP), 82947 (Glucose), 82390 (Serum ceruloplasmin), 80076 (Liver function tests), 82607 (Vitamin B12), 70551 (MRI brain without contrast), 78830 (DaTscan), 95885 (EMG)

SYNONYMS: Essential tremor, ET, benign essential tremor, familial tremor, hereditary tremor, action tremor, postural tremor, kinetic tremor, senile tremor, benign tremor

SCOPE: Diagnosis and management of essential tremor in adults. Covers diagnostic workup to differentiate from Parkinson's disease and other tremor disorders, pharmacologic and non-pharmacologic treatment options. Excludes enhanced physiologic tremor, drug-induced tremor, psychogenic tremor, and tremor as part of other movement disorders (PD, dystonia, cerebellar disease).

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DEFINITIONS: - Essential Tremor: Bilateral action tremor of the hands and forearms (± head tremor) without other neurologic signs, present for ≥3 years - Action Tremor: Tremor occurring during voluntary movement (includes postural and kinetic tremor) - Postural Tremor: Tremor present when maintaining a position against gravity (arms outstretched) - Kinetic Tremor: Tremor during voluntary movement (finger-to-nose) - Rest Tremor: Tremor present at rest with limb fully supported (typical of Parkinson's)

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DIAGNOSTIC CRITERIA (Consensus Statement, Movement Disorder Society):

Core Criteria: - Bilateral upper limb action tremor (postural ± kinetic) for ≥3 years - With or without head tremor - Without other neurologic signs (dystonia, ataxia, parkinsonism)

Supportive Features: - Family history of similar tremor - Beneficial response to alcohol - Absence of known causes

Exclusion Criteria: - Isolated focal tremors (voice, head only) - Orthostatic tremor - Task-specific tremors - Sudden onset or stepwise progression - Drug-induced tremor

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

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1. LABORATORY WORKUP

1A. Essential/Core Labs

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
TSH (CPT 84443)	-	ROUTINE	ROUTINE	-	Hyperthyroidism causes tremor	Normal (0.4-4.0 mIU/L)
Free T4 (CPT 84439)	-	ROUTINE	ROUTINE	-	If TSH abnormal	Normal
CMP (CPT 80053)	-	ROUTINE	ROUTINE	-	Electrolyte abnormalities, hepatic/renal function	Normal
Glucose (CPT 82947)	-	ROUTINE	ROUTINE	-	Hypoglycemia can cause tremor	Normal

1B. Extended Workup (Second-line)

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Serum ceruloplasmin (CPT 82390)	-	ROUTINE	ROUTINE	-	Wilson disease if <50 years or atypical features	20-40 mg/dL
24-hour urine copper	-	EXT	EXT	-	If ceruloplasmin low/borderline	<100 mcg/24h
Liver function tests (CPT 80076)	-	ROUTINE	ROUTINE	-	Wilson disease, hepatic encephalopathy	Normal
Serum copper (CPT 82390)	-	ROUTINE	ROUTINE	-	Wilson disease	Normal
Vitamin B12 (CPT 82607)	-	ROUTINE	ROUTINE	-	Deficiency can cause tremor	>400 pg/mL
Drug/toxin screen	-	ROUTINE	ROUTINE	-	Drug-induced tremor	Negative
Caffeine intake assessment	-	-	ROUTINE	-	Excessive caffeine exacerbates tremor	Assess

1C. Rare/Specialized

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Genetic testing (LINGO1, ETM1/2)	-	-	EXT	-	Family history, research interest	Informational
Anti-neuronal antibodies	-	-	EXT	-	If autoimmune cause suspected	Negative
Heavy metal levels	-	-	EXT	-	Mercury, lead exposure	Normal

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2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
Clinical examination	-	ROUTINE	ROUTINE	-	At diagnosis	Bilateral action tremor, no rest tremor, no parkinsonism	None
Handwriting sample	-	ROUTINE	ROUTINE	-	At diagnosis, follow-up	Large, tremulous writing (vs micrographia in PD)	None
Spiral drawing test	-	ROUTINE	ROUTINE	-	At diagnosis, follow-up	Objective tremor assessment	None

2B. Extended

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI brain without contrast (CPT 70551)	-	ROUTINE	ROUTINE	-	If atypical features or diagnostic uncertainty	Rule out structural cause, cerebellar lesions	Pacemaker, metal
DaTscan (CPT 78830)	-	-	ROUTINE	-	Differentiate ET from PD if uncertain	Normal in ET; reduced striatal uptake in PD	Pregnancy, iodine allergy
Accelerometry/Tremor analysis	-	-	EXT	-	Objective quantification, research	Characterize tremor frequency (4-12 Hz)	None
EMG (CPT 95885)	-	-	EXT	-	If neuropathic tremor suspected	Rule out neuropathy	None
MRI with susceptibility-weighted imaging	-	ROUTINE	ROUTINE	-	If Wilson disease suspected	Rule out basal ganglia T2 hypointensity	Per MRI

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3. TREATMENT

3A. First-Line Pharmacologic Treatment

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Propranolol (Inderal)	PO	-	20-40 mg :: PO :: BID :: Start 20-40 mg BID-TID; titrate to 120-320 mg/day in divided doses	Asthma, COPD, bradycardia, AV block, decompensated heart failure, depression	HR, BP	-	ROUTINE	ROUTINE	-
Propranolol LA	PO	-	60-80 mg :: PO :: daily :: Start 60-80 mg daily; titrate to 160-320 mg daily	Same	Same	-	ROUTINE	ROUTINE	-
Primidone (Mysoline)	PO	-	12.5-25 mg :: PO :: QHS :: Start 12.5-25 mg QHS; titrate very slowly by 12.5-25 mg/week to 250-750 mg/day in divided doses	Porphyria, severe sedation	Sedation, ataxia, nausea (start very low)	-	ROUTINE	ROUTINE	-

3B. Second-Line Pharmacologic Treatment

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Topiramate (Topamax)	PO	-	25 mg :: PO :: daily :: Start 25 mg daily; titrate by 25-50 mg/week to 100-400 mg/day in divided doses	Kidney stones, glaucoma, pregnancy	Cognitive effects, paresthesias, weight loss	-	ROUTINE	ROUTINE	-
Gabapentin (Neurontin)	PO	-	300 mg :: PO :: daily :: Start 300 mg daily; titrate to 300-600 mg TID (900-1800 mg/day)	Renal impairment (adjust dose)	Sedation, dizziness, edema	-	ROUTINE	ROUTINE	-
Alprazolam (Xanax)	PO	-	0.25-0.5 mg :: PO :: TID :: 0.25-0.5 mg TID; max 3 mg/day; use cautiously	Respiratory depression, addiction potential, elderly falls	Sedation, dependence, falls	-	ROUTINE	ROUTINE	-
Clonazepam (Klonopin)	PO	-	0.5 mg :: PO :: TID :: 0.5 mg TID; titrate to 2-4 mg/day	Same as alprazolam	Same	-	ROUTINE	ROUTINE	-
Atenolol	PO	-	50-100 mg :: PO :: daily :: 50-100 mg daily; less CNS penetration than propranolol	Same as propranolol	HR, BP	-	ROUTINE	ROUTINE	-
Nadolol	PO	-	40-160 mg :: PO :: daily :: 40-160 mg daily; long-acting, once daily	Same as propranolol	HR, BP	-	ROUTINE	ROUTINE	-

3C. Third-Line and Adjunctive Treatments

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Botulinum toxin (OnabotulinumtoxinA)	-	-	50-100 units :: - :: - :: 50-100 units per arm for hand tremor; 40-400 units for head tremor; q3 months	Infection at injection site, myasthenia	Weakness, dysphagia (head/voice injections)	-	-	ROUTINE	-
Propranolol + Primidone combination	-	-	N/A :: - :: per protocol :: Use lower doses of each; synergistic effect	Per individual agents	Per individual agents	-	ROUTINE	ROUTINE	-
Nimodipine	PO	-	30 mg :: PO :: TID :: 30 mg TID; limited evidence	Hypotension	BP	-	-	EXT	-
Zonisamide	PO	-	100-200 mg :: PO :: daily :: 100-200 mg daily; off-label	Sulfa allergy, kidney stones	Kidney stones, cognitive	-	-	EXT	-

3D. Interventional Treatments

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Deep brain stimulation (DBS)	-	-	N/A :: - :: continuous :: VIM thalamus target; bilateral or unilateral	-	Bleeding risk, active infection, severe cognitive impairment	Speech, gait, stimulator function	-	-	EXT	-
MRI-guided focused ultrasound (MRgFUS)	-	-	N/A :: - :: per protocol :: VIM thalamotomy; unilateral only	-	Skull density ratio issues, intracranial lesions	Speech, gait, sensory changes	-	-	EXT	-
Gamma Knife thalamotomy	-	-	N/A :: - :: per protocol :: VIM target; unilateral; delayed effect	-	Per radiosurgery	Same as MRgFUS	-	-	EXT	-

3E. Non-Pharmacologic Treatments

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Weighted utensils	-	-	N/A :: - :: per protocol :: Reduce tremor amplitude during eating	None	OT can assist with selection	-	-	ROUTINE	-
Wrist weights	-	-	N/A :: - :: per protocol :: Dampen tremor during activities	None	May cause fatigue	-	-	ROUTINE	-
Adaptive devices	-	-	N/A :: - :: per protocol :: Two-handled cups, rocker knives, button hooks	None	OT referral	-	-	ROUTINE	-
Cala Trio device	-	-	N/A :: - :: BID :: FDA-approved wrist-worn peripheral nerve stimulation; 2x daily for 40 min	Pacemaker/implanted device, pregnancy	Prescription medical device	-	-	ROUTINE	-
Limit caffeine	-	-	N/A :: - :: per protocol :: Caffeine exacerbates tremor	None	Patient education	-	ROUTINE	ROUTINE	-
Avoid triggers	-	-	N/A :: - :: N/A :: Stress, fatigue, stimulants worsen tremor	None	Patient education	-	ROUTINE	ROUTINE	-
Stress management	-	-	N/A :: - :: per protocol :: Relaxation techniques, biofeedback	None	Tremor worsens with anxiety	-	-	ROUTINE	-

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4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation	ED	HOSP	OPD	ICU	Indication
Movement disorder specialist	-	ROUTINE	ROUTINE	-	Diagnostic uncertainty, treatment-refractory tremor, DBS candidacy
Occupational therapy	-	ROUTINE	ROUTINE	-	Adaptive equipment, handwriting strategies, ADL assistance
Physical therapy	-	-	ROUTINE	-	Balance, gait training if affected
Speech therapy	-	-	ROUTINE	-	Voice tremor management
Neurosurgery	-	-	ROUTINE	-	DBS candidacy evaluation
Interventional radiology/MRgFUS center	-	-	ROUTINE	-	Focused ultrasound evaluation
Neuropsychology	-	-	ROUTINE	-	Pre-DBS cognitive assessment

4B. Patient/Family Instructions

Recommendation	ED	HOSP	OPD
ET is a chronic condition but does not reduce life expectancy	-	ROUTINE	ROUTINE
Tremor may worsen slowly over time but many patients do well with treatment	-	ROUTINE	ROUTINE
Alcohol provides temporary relief but is not a recommended treatment	-	ROUTINE	ROUTINE
Medications work best when taken consistently	-	ROUTINE	ROUTINE
Avoid caffeine and stimulants which worsen tremor	-	ROUTINE	ROUTINE
Get adequate sleep; fatigue worsens tremor	-	ROUTINE	ROUTINE
Join International Essential Tremor Foundation support network	-	-	ROUTINE
Inform doctors of ET before procedures (tremor may complicate surgery)	-	ROUTINE	ROUTINE

4C. Lifestyle & Prevention

Recommendation	ED	HOSP	OPD
Reduce or eliminate caffeine intake	-	ROUTINE	ROUTINE
Maintain regular sleep schedule	-	ROUTINE	ROUTINE
Stress reduction techniques	-	-	ROUTINE
Limit alcohol to social amounts (not as tremor treatment)	-	ROUTINE	ROUTINE
Regular exercise for overall health	-	-	ROUTINE
Use adaptive equipment for functional independence	-	-	ROUTINE

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5. DIFFERENTIAL DIAGNOSIS

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Parkinson's disease	Rest tremor (4-6 Hz), asymmetric onset, bradykinesia, rigidity, postural instability	Clinical exam; DaTscan reduced in PD
Enhanced physiologic tremor	Low amplitude, high frequency (8-12 Hz), associated with anxiety, caffeine, medications, hyperthyroidism	TSH, medication review, resolves with trigger removal
Drug-induced tremor	Temporal relationship to medication (lithium, valproate, SSRIs, stimulants, bronchodilators)	Medication review; improves with dose reduction
Dystonic tremor	Irregular, jerky, "null point" present, associated dystonic posturing	Clinical features; may respond to botox
Cerebellar tremor	Intention tremor worse at target, associated ataxia, dysmetria, other cerebellar signs	MRI brain; cerebellar atrophy/lesion
Wilson disease	Young onset (<50), KF rings, liver disease, psychiatric symptoms, varied movement disorders	Ceruloplasmin, 24h urine copper, slit lamp exam
Psychogenic tremor	Variable frequency, distractible, entrainment, inconsistent pattern, sudden onset	Clinical observation; psychiatric assessment
Orthostatic tremor	High frequency (13-18 Hz), occurs only when standing, relief with sitting/walking	EMG shows characteristic high frequency
Hyperthyroidism	Associated hyperthyroid symptoms (weight loss, palpitations, heat intolerance)	TSH, free T4
Rubral (Holmes) tremor	Combination of rest, postural, and action tremor; large amplitude; midbrain lesion	MRI brain showing midbrain pathology

6. MONITORING PARAMETERS

Parameter	ED	HOSP	OPD	ICU	Frequency	Target/Threshold	Action if Abnormal
Tremor severity (clinical rating scale)	-	ROUTINE	ROUTINE	-	Each visit	Improved or stable	Adjust medications
Functional impact (FTM, QUEST)	-	-	ROUTINE	-	q6-12 months	Minimal functional impairment	Add therapy, consider surgery
Handwriting sample/spiral drawing	-	ROUTINE	ROUTINE	-	Each visit	Stable or improved	Objective tracking
Heart rate	-	ROUTINE	ROUTINE	-	Each visit if on beta-blocker	HR >50	Reduce dose if bradycardic
Blood pressure	-	ROUTINE	ROUTINE	-	Each visit if on beta-blocker	SBP >90	Reduce dose if hypotensive
Sedation/cognitive effects	-	ROUTINE	ROUTINE	-	Each visit	Tolerable	Reduce dose or switch agent
Mood	-	ROUTINE	ROUTINE	-	Each visit	No depression	Monitor; beta-blockers can cause depression
TSH	-	-	ROUTINE	-	Annually if on medications	Normal	Adjust thyroid replacement if applicable

7. DISPOSITION CRITERIA

Disposition	Criteria
Outpatient management	Most patients; diagnosis confirmed, treatment initiated
Movement disorder referral	Diagnostic uncertainty, DaTscan consideration, treatment-refractory, surgical candidacy
DBS evaluation	Moderate-severe tremor refractory to medications, adequate cognitive function, no surgical contraindications
MRgFUS evaluation	Unilateral tremor dominant, medications failed, not DBS candidate, meets skull density criteria
Occupational therapy	Functional impairment with ADLs; need for adaptive equipment

8. EVIDENCE & REFERENCES

Recommendation	Evidence Level	Source
Propranolol effective for ET	Class I, Level A	Cochrane Reviews; AAN Guidelines 2011
Primidone effective for ET	Class I, Level A	Cochrane Reviews; AAN Guidelines 2011
Propranolol + Primidone combination	Class II, Level B	AAN Guidelines 2011
Topiramate effective for ET	Class I, Level B	AAN Guidelines 2011
Gabapentin possibly effective	Class II, Level U	AAN Guidelines 2011
Botulinum toxin for hand tremor	Class II, Level B	AAN Guidelines 2011
DBS effective for medically refractory ET	Class I, Level A	Multiple RCTs
MRgFUS (focused ultrasound) effective	Class I, Level A	Elias et al., NEJM 2016
DaTscan differentiates ET from PD	Class II, Level B	FDA approved 2011
Cala Trio wrist device	Class II, Level B	FDA approved 2018

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NOTES

• Essential tremor is often underdiagnosed and undertreated
• Family history present in ~50% of cases; autosomal dominant inheritance pattern
• Alcohol responsiveness is characteristic but NOT a recommended treatment strategy
• Tremor typically starts in hands; head tremor develops in ~50% over time; voice tremor in ~30%
• Propranolol and primidone are first-line; start LOW and titrate SLOWLY with primidone
• Many patients respond partially to medications; combination therapy often needed
• DBS is highly effective for medication-refractory cases; VIM thalamus is target
• MRgFUS (focused ultrasound) is incisionless alternative but only unilateral treatment recommended
• ET is associated with increased risk of cognitive impairment and Parkinson's disease (controversial)
• Differentiation from PD is clinical; DaTscan helpful in uncertain cases

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CHANGE LOG

v1.0 (January 29, 2026) - Initial template creation - Comprehensive pharmacologic options with tiered approach - Included interventional treatments (DBS, MRgFUS) - Added Cala Trio device and non-pharmacologic options - Differentiation from Parkinson's disease emphasized