In this article:

• Familial tremor: causes, symptoms and treatment options
• Is essential tremor hereditary?
• Symptoms of familial essential tremor
• Types of tremor
• Essential tremor vs Parkinson’s disease
• Diagnosing familial tremor
• Treatment options for essential tremor
• Advanced targeting with FAT1 imaging
• Frequently asked questions about familial tremor
• Essential tremor treatment in London

Familial tremor: causes, symptoms and treatment options

A tremor is a rhythmic, involuntary shaking movement affecting part of the body. Tremors can occur for a variety of reasons, including anxiety, stress, fatigue or excess caffeine intake, but they can also be caused by neurological conditions such as essential tremor (ET) or Parkinson’s Disease.

Essential tremor is one of the world’s most common movement disorders, affecting around 1% of the general population and up to 5% of people over the age of 60. It most commonly causes a hand tremor during movement or when holding a position, although it can also affect the head, voice, jaw and legs.

Many people with essential tremor have a family history of the condition. When essential tremor runs in families, it is often referred to as familial essential tremor.

Is essential tremor hereditary?

Familial essential tremor has a strong genetic component. Studies suggest that around 50–70% of cases may be inherited, and the condition is often described as following an autosomal dominant inheritance pattern. This means that if one parent carries the relevant altered gene, there may be a 50% chance of passing the condition on to their children.

However, the genetics of essential tremor are complex and not yet fully understood. Not everybody who inherits a genetic predisposition will develop symptoms, and severity can vary significantly between family members.

Research has identified several genes associated with essential tremor, but no single causative gene has been confirmed. There are likely many different genes that are responsible.

Familial forms of essential tremor often begin earlier in life than non-familial cases, although symptoms may still develop gradually over many years.

Symptoms of familial essential tremor

Essential tremor is usually an action tremor, meaning it occurs during movement or while maintaining a posture, rather than when fully relaxed.

Common symptoms include:

• Tremor in the hands and arms
• Shaking that worsens during activities such as writing, eating or using a smartphone.
• Tremor affecting both sides of the body.
• Head tremor or voice tremor.
• Symptoms that gradually worsen over time
• Tremor aggravated by stress, tiredness, caffeine or certain medications.

For some people, symptoms remain mild. For others, tremor can significantly affect daily life, work, social confidence and mental wellbeing.

Types of tremor

Tremors are broadly divided into two main categories: rest tremor and action tremor.

A rest tremor occurs when part of the body is fully relaxed and supported. This type of tremor is commonly associated with Parkinson’s disease.

Essential tremor is typically an action tremor. Action tremors include:

Postural tremor

Occurs when holding a position against gravity, such as holding the arms outstretched.

Kinetic tremor

Occurs during deliberate movement, such as eating or using cutlery.

Intention tremor

Worsens as the hand approaches a target, such as reaching for a cup.

Isometric tremor

Occurs during muscle contraction without movement, such as gripping a heavy object.

Task-specific tremor

Occurs during specific repetitive activities such as writing, speaking or playing an instrument.

Essential tremor vs Parkinson’s disease

Essential tremor and Parkinson’s disease are both movement disorders, but they are different conditions.

Essential tremor most commonly causes shaking during movement or activity, whereas Parkinsonian tremor more often occurs at rest.

Parkinson’s disease is also associated with additional neurological symptoms such as stiffness, slowness of movement, balance problems,changes in walking pattern as well as ‘non-motor’ symptoms such as constipation and reduced sense of smell.

Because symptoms can sometimes overlap, assessment by a neurologist specialising in movement disorders is important to ensure an accurate diagnosis.

Diagnosing familial tremor

Diagnosis usually begins with a detailed medical and family history alongside a neurological examination.

A neurologist will assess:

• The location and severity of the tremor
• Whether the tremor occurs during rest or movement
• How symptoms affect daily activities
• Whether other family members are affected

Clinic-based tests, that include drawing spirals or handwriting assessment, may help evaluate tremor severity.

Depending on the clinical presentation, additional investigations may occasionally be used to exclude other causes of tremor. These can include blood tests, MRI scans, CT scans, electromyography (EMG) or specialist imaging such as SPECT scans.

Treatment options for essential tremor

Medication

Medication is often the first-line treatment for essential tremor.

Common medications include:

• Propranolol
• Primidone

Some patients may also benefit from Botox injections, particularly for head or voice tremor but also for some types of limb tremor.

However, medication is not always effective, and some patients experience side effects such as fatigue, dizziness or nausea.

Surgical and procedural treatments

For people with medication-resistant essential tremor, several advanced treatment options are available.

Deep brain stimulation (DBS)

Deep brain stimulation is an established treatment for essential tremor and Parkinson’s disease.

The procedure involves implanting electrodes into specific areas of the brain connected to a battery device placed under the skin of the chest. Electrical stimulation helps regulate abnormal brain activity associated with tremor.

One advantage of DBS is that stimulation settings can be adjusted over time as symptoms change.

Radiofrequency ablation (RFA)

Radiofrequency ablation uses heat generated by radio waves to create a small, controlled lesion in a targeted area of the brain involved in tremor pathways.

MR-guided focused ultrasound (MRgFUS)

MR-guided focused ultrasound thalamotomy is an incisionless treatment for medication-resistant essential tremor.

The procedure uses focused ultrasound energy, guided in real time by MRI imaging, to create a precise lesion within the thalamus – a structure involved in tremor circuits.

Patients remain awake throughout treatment so the clinical team can assess tremor improvement during the procedure itself.

Many patients experience significant improvement in tremor in the treated hand during or shortly after treatment, although outcomes and potential side effects vary between individuals.

MRgFUS is used to reduce tremor on one side of the body. In selected patients, staged treatment of the second side (after many months) may also be considered.

At Queen Square Imaging Centre in London, patients are assessed by a specialist movement disorder and functional neurosurgery team with expertise in advanced tremor therapies including MR-guided focused ultrasound, DBS and lesioning procedures.

Whilst these procedures are all shown to be safe, they can be associated with a risk of possible side effects including speech, balance or coordination difficulties as well as other risks, explained by the treating teams.

Advanced targeting with FAT1 imaging

During MR-guided focused ultrasound, the target area for treatment, deep in the brain, is the Ventral Intermediate Nucleus (Vim) of the thalamus.

FAT1 imaging is an advanced imaging technique (using MRI) that combines high-resolution with diffusion tractography to support more individualised treatment targeting in selected patients.

This approach helps improve target visualisation based on each patient’s unique brain anatomy rather than relying solely on standard anatomical coordinates.

Frequently asked questions about familial tremor

Essential tremor treatment in London

If you think you may have familial essential tremor, the first step is to speak with a neurologist specialising in movement disorders.

Queen Square Imaging Centre in London offers specialist assessment and advanced treatment options for essential tremor and tremor-dominant Parkinson’s disease, including MR-guided focused ultrasound thalamotomy. Our multidisciplinary team works closely with experts in functional neurosurgery and movement disorders to provide personalised treatment recommendations for each patient.

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