Tremors: when a shake needs a work-up

A tremor has a shape, and the shape is the diagnosis. Whether it appears at rest or on action, whether one side or both, and whether anything else has slowed down narrows it to two or three possibilities before any test is done.

The three questions that sort it

• Does it happen when the hands are resting in the lap, or when they are being used? Rest tremor points one way, action and posture tremor another.
• Is it on both sides from the beginning, or did it start on one? One-sided onset matters more than almost anything else.
• Is anything else slow: walking, writing, the blink, the voice, the arm that no longer swings?

The common causes

• Enhanced physiological tremor: a fine, fast shake in both hands that everyone has and that becomes visible with caffeine, nicotine, anxiety, sleep deprivation, fever, low sugar, alcohol withdrawal and some medicines. It comes and goes with the day and does not progress.
• Essential tremor: the commonest true tremor disorder. Hands shaken when using them, when holding a cup or writing, sometimes the head nodding or the voice quivering, often both sides, often a parent with the same hands. It worsens slowly over years, it is not dangerous, and it is treatable. Alcohol temporarily reduces it, which is an interesting clue and a bad treatment.
• Parkinsonian tremor: a rest tremor, usually starting on one side, often in a hand, at a slower frequency, sometimes with the thumb rolling as if counting. Alongside it there is slowness, stiffness, reduced arm swing, a softer voice, smaller handwriting, a masked face, constipation, loss of smell and disturbed acting-out of dreams. It needs a neurologist and levodopa assessment, and the timing of that referral changes the next decade of a person's life.
• Drug-induced tremor, which is more common than any of the above three in a general clinic: salbutamol and similar inhalers, lithium, valproate, some antidepressants, caffeine tablets, and the gastric medicines in the metoclopramide and prokinetic group, which produce tremor, stiffness and restlessness and are still being given for years in this country.
• Cerebellar tremor: a shake that worsens as the hand approaches its target, with unsteady walking, slurred speech and erratic eye movements. That is the balance centre of the brain and it needs imaging, because the causes include multiple sclerosis, stroke, tumour, alcohol and thyroid or drug effects.
• Dystonic tremor, irregular and position-specific, often in the head or neck, eased by touching the part lightly.
• Orthostatic tremor of the legs, felt as unsteadiness the moment a person stands, with a rapid shake and relief on walking.
• Functional tremor, which appears suddenly, varies in frequency and distracts away when the person is asked to do something else with the other hand. It is real, it is not invented, and it is treatable.

The ones that must not be missed

• Wilson's disease: a young person with tremor, clumsiness, slurred speech, unexplained liver trouble, or a ring at the edge of the cornea. It is inherited, it is treatable, and missing it is fatal. Copper studies and a slit-lamp examination are quick.
• A tremor appearing suddenly with weakness on one side, facial droop, slurred speech or double vision. Stroke, and it is same-day emergency care.
• Tremor with confusion, fever, a stiff neck, or a rapidly deteriorating level of consciousness.
• Tremor with palpitations, weight loss, heat intolerance, sweating and anxiety, which is an overactive thyroid. Thyroid disease is not treated here, and it goes to an endocrinologist with the blood test.
• Tremor with repeated falls, or with a person burning themselves on a stove they can no longer control.
• Tremor after a head injury, or in anyone who has started a new medicine in the last month.
• Any tremor in a child or a young adult, which is not the usual pattern and needs a proper work-up rather than reassurance.

What we ask and what we look at

• When it started, which hand first, and what has changed. Progression over years is informative; onset over a day is an emergency.
• Whether it is present at rest, on holding the arms out, or on approaching a target, tested in that order.
• Everything the person can no longer do: buttoning, pouring, writing, eating with the hands, using a phone.
• Family history, since essential tremor travels in families.
• The full medicine list, including inhalers, gastric medicines, mood medicines and anything bought for the joints or the nerves. This single question resolves a surprising number of cases.
• Caffeine, nicotine, alcohol and sleep hours, counted honestly.
• Whether anything else has slowed: gait, arm swing, facial expression, speech volume, handwriting shown to us on paper.
• Bloods chosen by the picture: sugar, thyroid referred onward, liver and kidney function, calcium and magnesium, and copper studies in a young person.
• Referral to a neurologist for anything atypical, for any rest tremor, and for anything with imbalance, speech change or weakness.

What helps, once the cause is known

• Stopping or substituting the drug that is causing it, with the prescriber, which is the most effective intervention on this list and the least performed. Never stop a psychiatric or seizure medicine alone.
• Caffeine and nicotine reduced, sleep protected, and alcohol stopped as a self-treatment, since it rebounds and worsens the tremor later in the day.
• Essential tremor: propranolol or primidone are the standard treatments and they work for many people. Weighted cutlery, a thicker pen, a two-handed cup and a stable wrist rest are practical and immediate. In severe cases there are further options through a specialist.
• Parkinson's disease: levodopa and the other drugs change the day, and physiotherapy, speech therapy and occupational therapy change the years. Starting the pathway early is better than enduring it, and no herbal course substitutes for any of it.
• Cerebellar tremor is treated by its cause, and the balance work matters more than the shake.
• Functional tremor responds to the specific rehabilitation approach, and to being told clearly what it is.

Where Ayurvedic care sits

• Ashwagandha is the honest option here, for the anxiety-and-sleep component that amplifies a fine tremor, with reasonable human evidence behind it for how a person feels through a day.
• Medicated oils and a warm bath before bed help the stiffness and the sleep in the long-standing pictures, as support rather than treatment.
• Guduchi and bala as general nourishing support where the person is thin and exhausted, without claiming anything for the tremor itself.
• Sleep, meal regularity and stress reduction prescribed concretely, since these change an enhanced physiological tremor more than any preparation.
• What no herbal course does is treat Parkinson's disease, a cerebellar lesion or Wilson's disease. A tremor that is being managed with tonics while the person is slowing down is a tremor that has lost the years in which treatment helps most.

How we judge it

• Whether the tremor has changed side, and whether anything else has become slow or stiff. Progression is the finding that matters, not the shake itself.
• Tasks: pouring a cup of water, writing a line, buttoning a shirt, and the same photograph of the same handwriting at each review.
• Whether the causative medicine has been reviewed with the prescriber, and whether the thyroid and sugar have been tested.
• Whether a neurologist has seen it, since the treatments that alter the course of a tremor disorder are theirs.