Action

Occurs with voluntary contraction of muscle

Includes postural, isometric, and kinetic tremors

Postural

Occurs when the body part is voluntarily maintained against gravity

Includes essential, physiologic, cerebellar, dystonic, and drug-induced tremors

Kinetic

Occurs with any form of voluntary movement

Includes classic essential, cerebellar, dystonic, and drug-induced tremors

Intention

Subtype of kinetic tremor amplified as the target is reached

Presence of this type of tremor implies that there is a disturbance of the cerebellum or its pathways

Rest

Occurs in a body part that is relaxed and completely supported against gravity

Most commonly caused by parkinsonism, but may also occur in severe essential tremor

Abrupt onset

Absence of other neurologic signs

Changing tremor characteristics

Clinical inconsistencies

Employed in allied health professions

Litigation or compensation pending

Multiple somatizations

Multiple undiagnosed conditions

No evidence of disease by laboratory or radiologic investigations

Presence of psychiatric disease

Presence of secondary gain

Reported functional disturbances in the past

Responsive to placebo

Spontaneous remission

Static course

Tremor increases with

attention, and lessens with distractibility

Unclassified tremor (complex tremors)

Unresponsive to antitremor medications

Cerebellar tremor

Intention or postural tremor; ipsilateral involvement to lesion; abnormal finger-to-nose test; imbalance; abnormal heel-to-shin test; hypotonia

Head computed tomography or magnetic resonance imaging

Treat underlying cause, deep brain stimulation

Enhanced physiologic tremor

Postural tremor; low amplitude; use of exacerbating medication

Serum glucose level, thyroid-stimulating hormone level, liver function testing, patient history to evaluate for anxiety and caffeine use

Treat underlying cause, reassurance

Essential tremor

Postural tremor; symmetric; involves hands, wrists, lower extremities, head, or voice; family history; improvement with alcohol

No specific test; complete blood count, thyroid-stimulating hormone level, serum chemistry profile may rule out other disease

Propranolol (Inderal), primidone (Mysoline)

Parkinsonian tremor

Rest tremor; asymmetric; involves distal extremities; decreases with voluntary movement; bradykinesia, postural instability, and rigidity

No specific test; positron emission tomography or single-photon emission computed tomography for atypical presentation

Dopamine agonists, anticholinergics

Psychogenic tremor

Abrupt onset; spontaneous remission; extinction with distraction; changing tremor characteristics

Careful history

Mental health counseling