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Tremor

Medicine > Neurosciences

Differential Diagnosis Schema 🧠

Physiological Tremor

  • Enhanced physiological tremor: Often due to anxiety, stress, fatigue, or caffeine intake; typically fine and fast, affecting both hands.
  • Drug-induced tremor: Common with medications like beta-agonists, lithium, valproate, or corticosteroids; typically presents as a postural tremor.
  • Alcohol withdrawal: Tremor occurs within 6-12 hours of cessation, often coarse and affecting the hands.
  • Hyperthyroidism: Fine tremor associated with other symptoms like weight loss, tachycardia, and heat intolerance.
  • Hypoglycemia: Fine tremor associated with sweating, palpitations, and confusion; improves with glucose intake.
  • Fever: Tremor associated with elevated body temperature, often resolving with treatment of the underlying infection.
  • Metabolic disturbances: Tremor associated with electrolyte imbalances, such as hypocalcemia or hyponatremia.

Essential Tremor

  • Essential tremor: The most common movement disorder; typically a bilateral postural tremor of the hands and forearms, often familial, and may improve with alcohol.
  • Senile tremor: A variant of essential tremor seen in older adults; similar in presentation but often associated with aging.
  • Head tremor: May be associated with essential tremor; presents as a rhythmic shaking of the head (e.g., “yes-yes” or “no-no” movements).
  • Voice tremor: Tremor affecting the vocal cords, leading to a quavering voice; may occur in conjunction with essential tremor.

Parkinsonian Tremor

  • Parkinson’s disease: Resting tremor, typically unilateral and described as “pill-rolling”; associated with bradykinesia, rigidity, and postural instability.
  • Multiple system atrophy: Parkinsonian features with additional autonomic dysfunction; tremor is often less pronounced than in Parkinson’s disease.
  • Progressive supranuclear palsy: Parkinsonian features with vertical gaze palsy; tremor is less common but may be present.
  • Drug-induced parkinsonism: Tremor, rigidity, and bradykinesia caused by antipsychotics, antiemetics, or other dopamine-blocking drugs.
  • Lewy body dementia: Parkinsonism with fluctuating cognition and visual hallucinations; tremor is similar to Parkinson’s disease.
  • Wilson’s disease: A rare cause of parkinsonism in young patients; tremor may be present alongside hepatic dysfunction and psychiatric symptoms.
  • Vascular parkinsonism: Parkinsonian features due to cerebrovascular disease; tremor is less common, typically affecting the lower limbs.

Cerebellar Tremor

  • Cerebellar tremor: Intention tremor that worsens with voluntary movement and often associated with dysmetria, ataxia, and nystagmus.
  • Multiple sclerosis: May cause cerebellar tremor as part of a broader syndrome; often associated with other neurological signs.
  • Cerebellar stroke: Acute onset of cerebellar signs including tremor, dysmetria, and gait ataxia.
  • Friedreich’s ataxia: A hereditary ataxia associated with cerebellar signs including tremor, dysarthria, and gait disturbance.
  • Tumors: Space-occupying lesions in the cerebellum may present with tremor and other cerebellar signs.
  • Alcoholism: Chronic alcohol use can lead to cerebellar degeneration, presenting with tremor, ataxia, and cognitive impairment.
  • Trauma: Post-traumatic cerebellar tremor may develop following head injury involving the cerebellum.

Dystonic Tremor

  • Dystonic tremor: Occurs in a body part affected by dystonia; often irregular and may be relieved by certain postures.
  • Primary dystonia: Dystonia with tremor, such as in cervical dystonia (torticollis) or writer’s cramp.
  • Secondary dystonia: Caused by other neurological disorders, medications, or brain injuries, often presenting with tremor.

Key Points in History 🥼

Onset and Progression

  • Onset: Sudden onset may suggest stroke or trauma, whereas gradual onset is more common in degenerative conditions like Parkinson’s disease.
  • Duration: Determine if the tremor is acute, subacute, or chronic, as this can help narrow the differential diagnosis.
  • Progression: A progressive tremor suggests a degenerative or structural cause, while a non-progressive tremor may indicate a stable or functional disorder.
  • Triggering factors: Identify any factors that exacerbate or relieve the tremor, such as stress, caffeine, or alcohol consumption.
  • Temporal pattern: Establish if the tremor is present at rest, during postural maintenance, or with intentional movement.
  • Symmetry: Unilateral tremor is more common in Parkinson’s disease, whereas essential tremor typically affects both sides equally.
  • Family history: A positive family history may suggest a genetic cause such as essential tremor or Wilson’s disease.

Associated Symptoms

  • Neurological symptoms: Look for signs of bradykinesia, rigidity, gait disturbances, or cognitive changes, which may suggest a parkinsonian disorder.
  • Autonomic symptoms: Orthostatic hypotension, urinary incontinence, and constipation may point towards multiple system atrophy.
  • Visual symptoms: Diplopia, optic neuritis, or nystagmus may indicate multiple sclerosis or other cerebellar pathology.
  • Psychiatric symptoms: Anxiety, depression, or psychosis may be associated with functional tremor or Wilson’s disease.
  • Systemic symptoms: Weight loss, heat intolerance, or palpitations may suggest hyperthyroidism as a cause of tremor.
  • Exposure history: Document any history of toxin exposure (e.g., manganese, mercury), as this can lead to tremor.
  • Medication history: Review current and past medications for potential contributors to tremor (e.g., antipsychotics, beta-agonists).
  • Substance use: Alcohol, caffeine, and drug use (or withdrawal) can all be associated with tremor.
  • Trauma history: Consider any history of head or neck trauma, which may lead to post-traumatic tremor.

Background

  • Past medical history: Document any history of neurological disorders, thyroid disease, or psychiatric conditions.
  • Medication history: Consider any medications that may cause or exacerbate tremor, such as antipsychotics, antiemetics, or stimulants.
  • Family history: Explore any familial patterns of tremor or other neurological conditions.
  • Social history: Consider lifestyle factors such as alcohol consumption, drug use, and occupational exposure to toxins.
  • Surgical history: Previous surgeries, particularly neurosurgery, that may impact neurological function.
  • Travel history: Recent travel to areas endemic with infections like malaria or viral encephalitis, which could cause tremor.
  • Immunization status: Particularly for diseases such as influenza or hepatitis, which could indirectly affect neurological health.
  • Occupational history: Jobs involving exposure to heavy metals or other neurotoxins.
  • Dietary history: Consider malnutrition or vitamin deficiencies, particularly B12, as potential contributors to tremor.

Possible Investigations 🌡️

Laboratory Tests

  • Thyroid function tests: To rule out hyperthyroidism, which can cause a fine tremor.
  • Serum electrolytes: Particularly calcium and magnesium levels, which may influence neuromuscular excitability.
  • Liver function tests: To screen for hepatic causes of tremor, such as Wilson’s disease.
  • Copper and ceruloplasmin levels: Specific tests for Wilson’s disease.
  • Toxicology screen: To identify potential substance misuse or exposure to toxins that may contribute to tremor.
  • Blood glucose levels: To assess for hypoglycemia as a potential cause of tremor.
  • Vitamin B12 and folate levels: Deficiencies in these vitamins can lead to neurological symptoms including tremor.
  • CBC with differential: To rule out underlying infection or inflammation as a cause of tremor.
  • ANA and ESR: To investigate for autoimmune causes such as lupus, which can be associated with neurological manifestations.
  • Renal function tests: To assess for uremic tremor in patients with chronic kidney disease.
  • Genetic testing: If a hereditary condition like Huntington’s disease or essential tremor is suspected.
  • Infectious disease screening: For infections such as syphilis, HIV, or viral encephalitis, which may present with neurological symptoms.
  • Lactate and pyruvate levels: To assess for mitochondrial disorders that might present with tremor.
  • CSF analysis: If central nervous system infection or inflammation is suspected.
  • Paraneoplastic panel: To screen for paraneoplastic syndromes that may present with tremor and other neurological symptoms.
  • Hormonal assays: To investigate endocrine causes of tremor, such as pheochromocytoma or adrenal insufficiency.

Imaging Studies

  • MRI brain: Essential for identifying structural causes of tremor, such as stroke, tumor, or multiple sclerosis.
  • CT brain: Useful in acute settings to rule out hemorrhage or large masses causing tremor.
  • DaTSCAN: A specialized imaging study used to differentiate Parkinsonian syndromes from essential tremor.
  • PET scan: May be used in research settings or for specific cases to identify metabolic activity in the brain.
  • SPECT scan: Single-photon emission computed tomography can assess blood flow and metabolic activity in the brain.
  • EEG: Useful in patients with suspected seizures or other paroxysmal neurological events presenting with tremor.
  • Nerve conduction studies and EMG: To assess for peripheral nerve or muscle disorders contributing to tremor.
  • Ultrasound of the abdomen: If Wilson’s disease is suspected, ultrasound may be used to assess for hepatic involvement.
  • Cardiac monitoring: To assess for arrhythmias or other cardiovascular causes of tremor.

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Neurosciences