Snapshot A 62-year-old man reports involuntary shaking of both his hands, arms, and head. The hand shaking appears to worsen with writing, eating, or drinking from a cup. During periods of stress, his shakes worsens. He has noticed that drinking wine improves his symptoms. Family history is significant for his father also having similar symptoms. On physical examination, there is a 4-10 Hz tremor elicited when both of his arms are outstretched forward. There is no tremor at rest. Introduction Clinical definition a type of rhythmic oscillatory movement that occurs with posturing and action Epidemiology incidence 0.3-5.6% in the general population demographics affects males and females equally mean age is 35-45 years of age and incidence increases with age location bilateral hands and arm head larynx risk factors family history aging Pathophysiology unknown Associated conditions worsens with stress improve with alcohol intake Prognosis a progressive disorder no spontaneous remissions Presentation Symptoms worsening tremor with posturing and voluntary movement worsens with stress and voluntary movement improves with alcohol and rest Physical exam rhythmic and oscillatory movement that most commonly affects the hands and arms can be asymmetric may also affect the head and voice Studies Diagnostic criteria clinical diagnosis Differential Parkinsonian tremor these patients are expected to have a tremor at rest Physiologic tremor Dystonic tremor Cerebellar tremor most often presents as an intention tremor Drug-induced tremor Treatment Medical propranolol indication considered first-line treatment for essential tremor asthma is contraindication to propranolol use primidone indication considered first-line treatment for essential tremor Operative deep brain stimulation indication in patients unresponsive to treatment technique electrodes placed within the ventral intermediate nucleus of the thalamus Complications Complications can be a disabling disorder that may negatively affect quality of life