Coping With and Treating Essential Tremor

Essential tremor affects about one in 20 people in the United States and becomes increasingly common as we age. While the disease process is not life-threatening, the tremor can be annoying and even debilitating to some people.

Because the tremor gets worse when people try to use their hands, it can turn everyday activities, like drinking from a cup or writing a letter, into a challenge. In addition, many find the tremor to be socially embarrassing.

Two elderly hands intertwined
Kathleen Finlay / Getty Images


Many people prefer not to treat essential tremor with medications or surgery. If the tremor only causes minimal amounts of disability, the risks of side effects can outweigh the inconvenience of the tremor. In these conditions, people learn how to make adjustments in their lives to accommodate the tremor. Some tips include the following:

  • Use the hand with least tremor as much as possible, or use two hands to steady yourself.
  • Use lids and straws to avoid spilling beverages.
  • Pay attention to what makes your tremor worse (stress, caffeine, fatigue) and do what you can to avoid those provoking factors.
  • Use heavier pens and eating utensils.
  • If in a restaurant, ask that meat be cut in the kitchen, or order finger foods to avoid utensils. Consider asking that glasses be filled only half-way.
  • Change your morning routine by using an electric razor for shaving, and an electric toothbrush to improve control of your movements.
  • Steady your hands by resting your elbows on a countertop or guiding one hand with another when performing fine movements, such as applying makeup.
  • Try writing on a soft surface, like a magazine, in order to control the tremor while writing. Print instead of writing cursive.
  • Pick telephones with large buttons. Consider using a headset or speakerphone, as well as voice-activated dialing.
  • Set your computer to ignore double strikes on the keyboard. Consider voice-recognition technology.
  • Avoid stress, lack of sleep, and too much caffeine.

Medical Treatment

If the tremor is too disruptive, you may choose to take a medication to reduce the symptoms. The most common medications include beta-blockers, such as propranolol. The effectiveness of this medication varies from person to person, but it can be helpful in controlling hand tremor, as well as having some effect on tremor of the head, voice, and tongue.

Beta-blockers are also blood pressure medications, so it's possible that your blood pressure may drop too low, resulting in lightheadedness on this medication. Beta-blockers also control heart rate by slowing down the heart, which can be troublesome if your heart rate is already a little slow. People with asthma should be cautious about using beta-blockers, as this class of medication can worsen asthma attacks. Also, in people with diabetes, propranolol can mask symptoms of hypoglycemia, making it harder for patients to tell when their blood sugar is low.

Primidone is another useful medication for essential tremor. This medication is an anticonvulsant but has also been shown to sometimes lead to complete suppression of essential tremor. The most common side effects of primidone include nausea, dizziness, clumsiness, and drowsiness. Many other medications have some degree of usefulness in essential tremor but tend to be less effective than propranolol or primidone. These medications include

  • Atenolol
  • Sotalol
  • Topamax (topiramate)
  • Neurontin (gabapentin)
  • Xanax (alprazolam)

The medications reviewed are taken by mouth and tend to help hand tremor more than tremor of the head or voice. Injections of botulinum toxin A (Botox) has shown some utility in treating head or voice tremor. Injections into the arms have also been tried with some success. Botox works by weakening muscles, and so must be injected carefully to avoid weakness that becomes more of an impediment than the tremor itself.

Surgical Treatment

When essential tremor is truly disabling, and medication isn't working, surgical treatments may be considered. These include procedures known as stereotaxic thalamotomy or thalamic deep brain stimulation.

Stereotactic thalamotomy involves creating surgical lesions in part of the thalamus. This procedure is irreversible but has recently shown increasing benefit and fewer bad outcomes due to advances in neuroimaging techniques.

Deep brain stimulation involves electrodes being placed into parts of the brain that are involved with tremor. When the stimulator is turned on, the effect is to quiet down overactive parts of the brain, leading to reduced tremor. This is reversible and has better outcomes overall than thalamotomy, but is more expensive and requires time and effort for battery and hardware replacement and adjustments. Depending on where the electrical leads are placed, you may have side effects like slurred speech, paresthesias, or abnormal muscle contractions.

Surgical procedures should only be considered if medications have not controlled the tremor and the tremor is disabling. In addition, people with cognitive impairment and unstable medical illnesses are advised against having these procedures.

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  • International Essential Tremor Foundation. About Essential Tremor.

  • Zesiewicz, T.A., et al. (2011). Evidence-based guideline update: treatment of essential tremor: report of the Quality Standards subcommittee of the American Academy of Neurology. Neurology, Nov 8;77(19):1752-5. Epub 2011 Oct 19. Review.

By Peter Pressman, MD
Peter Pressman, MD, is a board-certified neurologist developing new ways to diagnose and care for people with neurocognitive disorders.