Tremor is the most common involuntary movement disorder. in the primary care setting the most common causes of tremors are essential tremors, Parkinson’s disease and enhanced physiologic tremor.

• The majority of patients with tremor have variable associated symptoms, depending on the underlying etiology.

It is important to investigate the following features of tremor in patients history in order to reach the underlying cause of tremor: ^[1][2][3]

• Mode of Onset, Unilateral or Bilateral
• Type of tremor (resting or action)
• Symmetric or Asymmetric
• Associated signs and symptoms
• Aggravating and relieving factors
• Medications
• Family history

• Common associated symptoms of essential tremor include:
  • Tremor in hands and arms bilaterally
  • Symmetric tremors
  • Haed nodding
  • Aggravated by stress, hands outstretched
  • Releived from alcohol
  • Other neurologic signs are absent
  • Essential tremor is diagnosed according to International Parkinson and Movement Disorder Society (IPMDS) guidelines^[4]:
    • Bilateral action tremor of upper limbs
    • Absence of other neurological signs
    • Long duration, more than 3 years
    • Absence or presence of tremor in other locations

• Common associated symptoms of Parkinsons Disease include:
  • Tremor decreases in intensity with voluntary movement
  • Bradykinesia
  • Stooped posture
  • Cogwheel rigidity
  • Micrographia
  • Ataxia
  • Apathy
• Common associated symptoms of enhanced physiologic tremor include:
  • Occurs while maintaining position against gravity
  • Enhanced with sympathetic stimulation (e.g., stress)
  • Normal neurological examination

Less common causes of tremor include: ^[1][5]

• Stroke: Tremor acute in onset, headache, vertigo, imbalance.
• Orthostatic Tremor: Shaking of legs upon standing, subjective feeling on imbalance and fall. Relieved by sitting down.
• Hyperthyroidism: Postural tremor, weight loss, palpitations, excessive sweating, nervousness, feeling overheated.
• Hypoglycemia:Tremor, sweating, dizziness, hunger, irritability.
• Neuropathic: Tremor, numbness, tingling, weakness
• Panic disorder: Tremor, suffocation, chest tightness, palpitations
• Benzodiazepine withdrawal: Hand tremor, sleep disturbance, irritability, sweating, nausea, difficulty concentrating.