Essential Tremor

If your hands shake so badly when you try to write, eat, or drink that it's affecting your daily life — and your tremor gets worse when you're using your hands, not resting — you may have essential tremor. It is the most common movement disorder in adults, and it is now more treatable than ever.

What Is Essential Tremor?

Essential tremor (ET) is the most common movement disorder, affecting roughly 4–5% of adults over 40 and up to 10% of adults over 80. It causes an action tremor (worst when using the hands, not at rest), most commonly of the hands, but also the head, voice and legs. Despite affecting millions, ET is poorly understood and under-recognized.

Treatment starts with medications (propranolol or primidone) but these only control tremor well in about 50% of patients. For people who don't respond or can't tolerate medications, highly effective interventional options now exist.

At a Glance

Essential tremor is the most common movement disorder — affects ~4-5% of adults over 40
It is an action tremor (worst when using hands), not a resting tremor like Parkinson's
Propranolol and primidone are first-line medications — effective in ~50% of patients
Three surgical options: deep brain stimulation (DBS), Gamma Knife thalamotomy, focused ultrasound (Exablate) — all targeting the ventral intermediate (VIM) nucleus of the thalamus
Focused ultrasound is now FDA-approved and offers immediate tremor control with no incision

Symptoms

Diagnosis

Clinical diagnosis — based on history and exam; no definitive lab test or imaging
- Key features: bilateral action tremor of hands for ≥3 years, normal neurologic exam, no other cause identified
DaTScan SPECT — can differentiate ET from early Parkinson disease when uncertain; normal in ET
Brain MRI — performed to rule out structural lesion before intervention planning

Types

Classic ET — bilateral hand action tremor; most common
Head/neck ET — isolated head tremor, sometimes with voice involvement
Task-specific tremor — writing tremor, voice tremor
ET-plus — ET with additional neurologic findings (tandem gait difficulty, mild cognitive symptoms) — intermediate between classic ET and Parkinson disease

Types

Medications (first-line)

Propranolol (non-selective beta-blocker): ~50% reduction in amplitude; best evidence
Primidone (barbiturate-class antiepileptic): ~50% reduction; use increases slowly from low dose
Second-line: gabapentin, topiramate, nadolol

Deep brain stimulation (DBS) — thalamic VIM target
Implanted electrode with continuous stimulation. Adjustable and reversible. ~85-90% tremor reduction. Preferred for younger patients or when bilateral treatment is needed (bilateral DBS vs. unilateral focused ultrasound).

Gamma Knife thalamotomy
Non-invasive lesion of VIM thalamus using focused radiation. Effect develops over 1-2 months. Good for patients who cannot undergo surgery.

Focused ultrasound (MRgFUS — Exablate)
FDA-approved 2016 for essential tremor. Uses 1,024 ultrasound beams focused through the skull to create a permanent tiny lesion in the VIM thalamus — in a 3-hour outpatient procedure in an MRI scanner. ~50% complete elimination and ~90% meaningful reduction in treated hand tremor. Currently approved for unilateral treatment only.

Treatment

Medications (First-Line)

Propranolol: A non-selective beta-blocker that provides about a 50% reduction in tremor amplitude and has the strongest clinical evidence.
Primidone: An antiepileptic medication that also provides about a 50% reduction. We start this at a very low dose and increase it slowly.
Second-line options: Medications such as gabapentin, topiramate, or nadolol may be used if first-line options are not effective.

Deep Brain Stimulation (DBS)
This involves safely implanting a thin electrode in the brain (targeting the VIM thalamus) that provides continuous, adjustable and reversible electrical stimulation. It offers an 85% to 90% reduction in tremor. This is often the preferred option for younger patients or those who need treatment for both sides of the body.

Gamma Knife Thalamotomy
A completely non-invasive procedure that uses focused radiation to treat the VIM thalamus. The effects develop gradually over 1 to 2 months. This is a very good option for patients who cannot safely undergo traditional surgery.

Focused Ultrasound (MRgFUS — Exablate)
FDA-approved in 2016 for essential tremor, this innovative, incisionless procedure uses 1,024 ultrasound beams focused through the skull to create a tiny, permanent treatment area in the VIM thalamus. It is a 3-hour outpatient procedure performed inside an MRI scanner. It completely eliminates the tremor for about 50% of patients and provides a meaningful reduction for about 90% of treated hands. It is currently approved for treating one side of the body at a time.

Outcomes

Treatment	Tremor reduction (hand)	Notes
Propranolol or primidone	~40-50%	May diminish over time; side effects limit use
DBS (VIM thalamus)	~85-90%	Adjustable; preferred for bilateral/younger patients
Gamma Knife thalamotomy	~70-80%	Non-invasive; takes 1-2 months; not adjustable
Focused ultrasound (MRgFUS)	~75-85%	Immediate; incisionless; FDA-approved; unilateral only

References

Elias WJ, et al. A pilot study of focused ultrasound thalamotomy for essential tremor. NEJM. 2013;369:640-648. PMID: 23944301
Elias WJ, et al. MR-guided focused ultrasound thalamotomy for essential tremor. NEJM. 2016;375:730-739. PMID: 27557300
Deuschl G, et al. Consensus statement of the Movement Disorder Society on essential tremor. Mov Disord. 1998;13:84-96. PMID: 9827589
Hariz MI, et al. Deep brain stimulation for essential tremor: a meta-analysis of the literature. Mov Disord. 2008;23:1816-1821. PMID: 18668637

Our Specialists

Peter Warnke, MD

Neurosurgery

David Satzer, MD

Neurosurgery

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