Tremor: causes, types and treatment

A tremor is a rhythmic, involuntary movement of part of the body. The hands are the commonest site, but the head, voice, legs and trunk can shake too. The NHS describes it as being unable to control shaking or trembling in part of your body.

Doctors group tremors by when they appear. A resting tremor shows when the body is relaxed, for example with the hands in the lap. An action tremor appears when you move or hold a position, such as lifting a cup or holding your arms out. This distinction is the first clue to the cause.

Because so many things can make a tremor visible, the label alone says little. The useful question is what the pattern is, how long it has been there, and whether other symptoms come with it.

Everyone has a tiny physiological tremor. The NHS lists things that often make it more obvious: getting older, stress, tiredness, anxiety or anger, caffeine in tea, coffee or cola, alcohol, smoking, and feeling very hot or cold.

Some medicines and health conditions can also cause a tremor. The NHS advises speaking to your GP before stopping any prescribed medicine. Parkinson’s UK adds that some antidepressants, asthma medicines, epilepsy medicines and anti-sickness pills can make a tremor worse, and the patient information leaflet will say if a medicine can do this.

An overactive thyroid is one medical cause worth knowing. The NHS lists twitching or trembling among its symptoms, together with weight loss, palpitations, heat sensitivity and anxiety. A blood test can check thyroid function.

The table summarises three patterns patients are often told about. It draws on the National Tremor Foundation, Parkinson’s UK and the NHS dystonia page. Only a specialist can say which applies to a particular person, and some people have more than one.

The National Tremor Foundation calls essential tremor one of the most common movement disorders and says it is estimated to be eight to ten times more common than Parkinson’s disease. It can affect any age, though it is more often noticed in older people. In the vast majority of cases it is inherited.

The shaking tends to be most visible when a position is held or during a task. Writing, drinking from a cup, eating, sewing, shaving and dressing can all become harder. After the hands, the head is the next most frequently affected area, followed by the voice, tongue, legs and trunk.

The charity says it is slowly progressive in some people but may be relatively non-progressive in many, and may stay mild throughout life. It describes the social impact as real: embarrassment can lead people to withdraw from activities they enjoy.

The NHS lists involuntary shaking, slow movement and stiff muscles as the main symptoms of Parkinson’s disease, and says it is caused by loss of nerve cells in part of the brain, which reduces dopamine. Most people start to develop symptoms when over 50.

Parkinson’s UK says tremor is common but not universal. A resting tremor is the most usual form, often affecting hands and legs, and it can worsen with stress, concentration or excitement. Some people feel internal tremors that others cannot see. For some, tremor is the main symptom that needs managing, which the charity calls tremor-dominant Parkinson’s.

The NHS says a GP may refer you to a specialist for tests if a tremor could be a symptom of Parkinson’s disease or multiple sclerosis.

The NHS says a GP may examine you and ask about other symptoms, any medicines you take, and your and your family’s medical history, because some types run in families. A mild tremor with no other cause may simply be monitored.

A specialist, usually a neurologist, may ask you to relax your hands and then to carry out a simple action such as drinking from a glass. Parkinson’s UK says they may also ask how often the tremor occurs, where on the body, how large it is and whether relatives are affected.

The National Tremor Foundation says brain scans such as MRI or CT can help rule out other causes, blood tests can check for thyroid or copper problems, and a DaTSCAN can help tell essential tremor from Parkinson’s tremor. It adds that the diagnosis of essential tremor remains largely a visual one.

The NHS says that if a tremor affects your life, a GP may prescribe medicine. It will not cure the tremor but often reduces the shaking. You may take it all the time or only before a situation that makes the tremor worse. For head or voice tremor, injections to block nerves and relax muscles may be offered. Rarely, brain surgery may help severe tremor that medicines do not control.

Parkinson’s UK describes deep brain stimulation, which uses electrodes in the brain, and focused ultrasound. It says focused ultrasound is available on the NHS for essential tremor but is not currently recommended for Parkinson’s tremor.

• Relaxation, gentle movement such as tai chi or yoga, and managing stress, because anxiety can make a tremor worse.

• Weighted wrist pads, bendable cutlery and easy-grip cups, which an occupational therapist can suggest.

• Cutting back on caffeine if it seems to make the shaking worse, as the NHS lists caffeine as a trigger.

• Telling family and friends, and planning ahead for social situations, to reduce embarrassment.

On the NHS the first step is usually a GP, who checks medicines and may arrange blood tests before referring to neurology. Waiting times for a neurology appointment vary by area.

Some people choose to see a private neurologist for an earlier opinion, MRI or DaTSCAN, and then continue on the NHS for long-term care. Focused ultrasound and deep brain stimulation are specialist treatments offered through selected centres.