Red flag symptoms - Tremor

Symptoms of tremor may be physiological or pathological and can display varying degrees of severity, writes Dr Suneeta Kochhar.


Red flag symptoms

  • Sudden onset
  • Progressive
  • Stepwise (suggestive of stroke or MS)
  • Neurological deficits
  • Age under 50 years in the absence of family history of essential tremor

Tremor may be described as involuntary, rhythmic, oscillatory movements. It may be physiological or pathological, with varying degrees of severity.

It may involve the head and neck area, the trunk or the limbs. There may be voice changes or writing difficulties.

Tremor may be caused by pathology affecting the brain stem, the cerebellum and/or the extrapyramidal system.

A patient may delay presenting with tremor, mistakenly believing it to be a normal part of ageing. Up to 4% of people aged over 65 years in the UK are affected by essential tremor (action or postural tremors).

Types of tremor

Physiological tremor
Physiological tremor may become apparent with anxiety, fatigue, hyperthyroidism, hypoglycaemia, alcohol or other drug withdrawal, and caffeine consumption. It may affect both hands equally.

Pathological tremor
The most common pathological tremors include resting tremor associated with parkinsonism, essential tremor and intention tremor, which may be due to cerebellar dysfunction. In the latter, possible causes include MS, spinocerebellar degeneration and stroke.

Tremor may be described as having slow or fast oscillations that vary in amplitude.

Resting tremor
Occurs at rest, may not be apparent during physical activity

Action tremor
Exacerbated on movement

Intention tremor
Occurs during voluntary movement towards a target. Tremor becomes worse as the target is approached

Complex tremor
May have components of resting, action and intention tremor. For example, Holmes tremor may occur in MS if the midbrain is affected

Essential tremor
Tends to be symmetrical and may affect the voice. Ask about a positive family history of this condition.

Other types of tremor include asterixis, affecting the hand, (flapping tremor, or liver flap), and postural tremor, occurring when the patient maintains a position against gravity such as holding the arms outstretched.

If Parkinson's disease is suspected, there may be other symptoms, such as bradykinesia (slow movement), cogwheel rigidity and a shuffling gait. The tremor is usually unilateral but may become generalised as the disease progresses. There is a reduced arm swing on walking.

Extrapyramidal symptoms and cognitive problems may be suggestive of progressive supranuclear palsy.

Some medications may cause tremor, including salbutamol, haloperidol and metoclopramide.

Possible causes

  • Parkinson's disease
  • Drugs (causing secondary parkinsonism)
  • Alcohol withdrawal
  • Hyperthyroidism
  • Hypoglycaemia
  • Stroke
  • Cerebellar space-occupying lesions
  • MS

Clinical assessment

It is important to evaluate tremor by taking a thorough history, which should include its onset and the body part affected. Possible exacerbating factors include rest, movement, stress, anxiety and alcohol.

In the case of a sudden onset of tremor, recent illness or the addition of a new medication should be considered.

A neurological disorder may be responsible, depending on the presence of other symptoms, such as weakness, numbness, dysarthria, confusion, postural problems, shuffling gait and cogwheel rigidity. Weight loss, palpitations and diarrhoea may point towards hyperthyroidism.

It is relevant to ask about a positive family history of tremor in first-degree relatives. It is also important to ask about alcohol and/or drug misuse and caffeine consumption. The effect on activities of daily living should be elicited.

Physical examination should include a full neurological assessment of the CNS and peripheral nervous system, as well as routine observations, such as temperature. Lying and standing BP measurements may be helpful.

Cerebellar function should be tested. This may be done by heel-to-shin and finger-to-nose testing.

It may be relevant to examine the neck to assess the thyroid gland and to assess for any associated eye signs.

Other useful tests include asking the patient to write a sentence to evaluate their handwriting, as well as asking them to hold a glass of water.

It may be relevant to look for cognitive dysfunction; for example, Lewy body dysfunction may present with resting tremor, cognitive dysfunction and visual hallucinations.

The tremor should be assessed at rest, with the arms outstretched and when the patient is distracted.

Parkinson's disease may be suspected in the presence of a resting tremor - this may affect the chin, voice or lower limbs. Cerebellar dysfunction is more likely in the presence of intention tremor. Physiological or essential tremor is more likely to be postural.

Gait ataxia, dysarthria, dysdiadochokinesia and intention tremor may be features of cerebellar pathology. Cerebellar lesions may cause ipsilateral limb ataxia.

Clinical evaluation is likely to reveal the underlying aetiology, although neurological referral may be necessary.

TFTs, calcium and glucose levels may be checked. Brain imaging may be required.


Management can include avoiding known triggers, such as caffeine and anxiety. Essential tremor may respond to beta-blockers.

Occupational therapy and physiotherapy may be helpful in cerebellar tremors. Specific therapy may be considered in patients who have Parkinson's disease.

For severe tremor, surgical management, such as thalamic deep brain stimulation, may be appropriate.

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  • Dr Kochhar is a GP in Bexhill-on-Sea, East Sussex

This is an updated version of an article that was first published in May 2015.

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