Tremors (muscle tremors, tremors)

Tremors can have many causes: Parkinson's disease, drug side effects, and thyroid disorders are just three of many. More about triggers and shapes

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Symbolic for trembling: the restless hand

Trembling (medical: tremor) is actually a normal action of the body. Our muscles always tremble a little without us noticing. This physiological tremor can intensify and become visible, for example when it is cold. Visible tremors are characterized by involuntary, usually rhythmic movements of various parts of the body: hands or arms, head, voice, legs or trunk. Often the muscle groups that are responsible for opposing actions tense alternately. If we are cold, these measures should "heat up" the body. Fear, excitement or exhaustion can also, figuratively and literally, "make your knees tremble". Excess caffeine or nicotine can also trigger the reaction at times.

The unintentional muscle movement can also be due to illness. Because there are many possible causes, finding the exact trigger is not that easy. A thorough medical examination by your family doctor and / or neurologist helps to narrow down the exact diagnosis. As a rule, the doctor checks the function of the brain, nerves and muscles in particular.Laboratory tests, imaging tests, such as magnetic resonance imaging, and other tests provide clues about underlying diseases. Certain medications can also be used as triggers. Many types of tremors can be treated.

Doctors differentiate between different types of tremor. Certain distinguishing features help them to do this, for example the question of how long the tremor has existed and whether the person affected may have other movement disorders. This could be, for example, a changed gait pattern or a noticeable muscle stiffness. The doctor should also be informed about psychological changes.

Answers to the following questions are particularly important when isolating a tremor:

  • When does the tremor occur?
  • How fast is the trembling movement?
  • How expansive is the trembling movement?

When does the tremor occur?

- There is rest tremor. As the name suggests, it starts when the affected body region is not moving and does not have to be held against gravity.
Example: The hand always starts to tremble when it is completely relaxed in the lap. However, as soon as the hand is raised, for example to reach for a coffee cup, the shaking decreases or stops completely. It therefore has little effect on the person concerned in everyday life. Nevertheless, the tremor of rest can of course be perceived as stressful.

- As the name suggests, an action tremor begins with a muscle action. There are again variants:

- - The tremor of movement generally starts with deliberately controlled movements, for example lifting the arm in the direction of the coffee cup.

- - The intention tremor is always noticeable when a very specific goal is approached.
Example: The tremor begins when the hand is aiming at the handle of the coffee cup and increases the closer the fingers get to the target. The finger-nose experiment is an informative medical test: the patient should touch the tip of his nose with his index finger in a relatively sweeping, large movement. The intention tremor occurs when the finger moves towards the tip of the nose and gets stronger the closer it gets to the target. So the tremor makes it difficult or impossible to complete the task.

- - The holding tremor describes a tremor when holding against gravity.
Example: If the coffee cup is held up for a while with an outstretched arm, the arm begins to tremble.

How fast is the trembling movement?

Doctors classify tremors according to frequency: There is the low-frequency tremor, i.e. a relatively slow tremor with a frequency of 2 to 4 Hertz (Hertz = vibrations per second). In addition, there is the medium-frequency tremor with a frequency of 4 to 7, and the high-frequency tremor, i.e. a rapid tremor, with a frequency of over 7 Hertz.

How expansive is the trembling movement?

A distinction is also made between the coarse (i.e. very expansive) tremors, the medium and fine (i.e. minimally expansive) tremors.

Confusing variety and how tremors can still be classified more closely

- A resting tremor, for example, is a characteristic (but not a conclusive!) Sign of Parkinson's disease or Parkinson's syndrome. The frequency is usually 4 to 6 or 7 Hertz, so it is a medium-frequency tremor. If the hands are affected - often it is just one of the two - it typically looks a bit like the patient is counting invisible coins. That is why this tremor is also called a coin counter tremor.

Parkinson's can also cause other forms of tremors. And not all resting tremors are caused by Parkinson's disease. For example, some medications can also trigger this type of tremor.

The therapy depends primarily on the cause (for Parkinson's see below: "Overview: The three most common forms of tremor").

- an intention tremor, that is, trembling when moving in a targeted manner, often has its cause in the cerebellum, medically the cerebellum. This type of disorder is therefore also called "cerebellar tremor". A common cause is multiple sclerosis. An intention tremor can also have other triggers. It can occur with persistent alcohol abuse or it can be caused by some drugs, for example lithium.
Therapy: Here too, doctors address the underlying disorder whenever possible. The doctor decides individually for each patient to what extent a drug suspected as a trigger can be changed. However, do not discontinue a prescribed medication on your own without consulting your doctor. Medicines that neurologists use more often against tremors, for example certain anticonvulsant drugs or beta blockers, occasionally show effects in this type of tremor. If the indication is very strict, so-called deep brain stimulation ("brain pacemaker", see "essential tremor") can also be considered in individual cases. Your doctor and / or a neurologist or neurosurgeon will advise you in detail whether this procedure is really an option.

- A tremor, which mainly appears as a postural tremor, can be an intensified and therefore visible form of "normal", physiological tremors - especially if it has a medium to higher frequency. Muscle exhaustion or anxiety, for example, can be triggers, followed by different drugs. Poisoning, alcohol, drug or medication withdrawal can also increase "normal" tremors. A rather coarse tremor occurs, for example, in severe liver or kidney diseases (more on this in the section: "Overview: The three most common forms of tremor" below).

- More rarely, the copper storage disease Wilson's disease is behind a gross holding and intention tremor. With this hereditary disease, the body excretes too little copper. The result is harmful copper deposits, especially in the liver, eyes and brain.
Symptoms: The suspicion arises above all if there are other neurological symptoms in addition to the tremor - especially in younger patients, and if there are already cases of illness in the relatives.
Diagnosis: Blood and urine tests, as well as an eye examination, are groundbreaking. A yellow-green ring around the cornea is often noticeable.
Early diagnosis and "decoppering" therapy are important to prevent (further) organ damage. So-called chelators, copper-binding drugs, are suitable for this.

- Essential tremor is the name of a very common form of tremor, which occurs predominantly as a holding tremor, very rarely as a resting tremor, in some of those affected as an intention tremor. More about this in the section: "The three most common forms of tremor".

The exact causes of the rather rare orthostatic tremor are also unclear.
Symptoms: It manifests itself as a high-frequency, not always visible tremor of the leg muscles. However, it can be palpable or registered by an electrophysiological examination. Patients feel unsteady when standing, and sometimes even fall when they stand. They rarely have problems walking, but not when they are lying down or sitting.
Therapeutically, neurologists use the drug gabapentin, among other things.

- The task-specific tremor is limited to very specific, mostly very specialized activities, For example, writing with a pen or playing an instrument, or it occurs as a voice tremor, thus impairing speech.
Therapy: Certain exercise methods have been developed to treat writing tremors. Special devices should also be able to improve handwriting. With voice tremor, neurologists try to improve speaking with a beta blocker or botulinum toxin.

- The position-specific tremor sets in with very specific postures. The exact classification of the clinical picture plays a role for the therapy. Neurologists are also usually guided by their experience with certain treatments.

- The dystonic tremor is typically associated with dystonia. These include various movement disorders, which are usually noticeable in the form of cramps or poor posture. One example is the spastic torticollis as a nerve disorder. Recurring painful spasms of the neck muscles lead to involuntary head postures forwards, backwards or to the side.
Diagnosis: The frequency and amplitude of this tremor are often irregular, which actually doesn't quite fit the definition of the tremor. Sometimes it is not possible for the neurologist in the first step to differentiate the dystonic tremor from a Parkinson's tremor (see below). If necessary, a special imaging method from nuclear medicine called brain function SPECT (single-photon emission computed tomography, FP-CIT-SPECT) can help.
Therapy: Botulinum toxin can act more frequently against dystonic tremors in certain parts of the body, for example the head or voice.

- The so-called Holmes tremor, mostly a slow, less rhythmic rest, holding and intention tremor, is caused by damage or degeneration of the central nervous system. A stroke can sometimes be the cause.
Therapy: With various drugs, for example anticholinergics (inhibit the transmission of excitation to nerve endings), dopaminergics (are also used in Parkinson's disease) or a drug such as clozapine, an attempt is made to achieve an improvement.

- Finally, nerve damage, so-called neuropathies, can be accompanied by tremors (neuropathic tremor). This rather rare form of tremor is usually coarse and of medium to high frequency. Sometimes, for example, it is caused by autoimmune inflammatory diseases that affect nerves. Sometimes special hereditary diseases are responsible for a neuropathic tremor.
Therapy: The doctor treats basic illnesses as specifically as possible, to which the tremor usually responds. Otherwise, neurologists may use beta blockers or certain anti-epileptic drugs.

- Last but not least, tremors can also be psychological (psychogenic tremor). This is indicated, for example, by a very unusual and "unphysiological" combination of different types of tremors. If the trembling begins and ends very abruptly, if the type or strength of the trembling changes when distracted, this can also be an indication of a psychological trigger. The examination of the muscle tension provides further information.

Overview: The three most common forms of tremor

In terms of frequency, the most important types of tremors are increased "normal" physiological tremors, essential tremors, and Parkinson's tremors. Therefore, more information about these three forms.

Increased "normal" physiological tremor

Causes: Triggers such as severe stress, muscular exhaustion, emotions, such as pronounced fear, extreme excitement or coldness are usually easy to understand. Medicines, internal illnesses and poisoning are also possible. However, the diagnosis always includes that the doctor will rule out a neurological disease. Depending on the cause and the appropriate therapy, this tremor can also regress again.
- - Triggering drugs: for example certain (especially so-called tricyclic) antidepressants, lithium, valproic acid, some asthma drugs, antiarrhythmics, psychotropic drugs such as neuroleptics, tamoxifen (a so-called anti-estrogen that is used in the treatment of breast cancer), some cytostatics (anti-cancer drugs ) and immunosuppressants.
- Internal illnesses as possible causes: overactive thyroid, overactive parathyroid, hypoglycaemia, low calcium level in the blood, vitamin B12 deficiency, kidney failure (kidney failure).
Poisoning also plays a role: alcohol intoxication and withdrawal, drug withdrawal, various poisons.
Symptoms: A rather higher-frequency tremor above 6 Hertz, which is particularly evident in holding positions (see explanation above).
Diagnosis: A detailed neurological examination is essential in most cases. Depending on the suspected diagnosis, the neurologist will coordinate with the internist at an early stage. In neurological diagnostics, an electromyogram (measurement of electrical potentials in muscles) and a lumbar puncture can be useful. Depending on the question, laboratory examinations and imaging procedures of different lengths are sometimes necessary.
Therapy: It depends on the cause and its treatability. If a drug has been found to be the trigger, the doctor will check to what extent a change is possible here. Otherwise, the neurologist will weigh up whether a beta blocker, for example, is an option if the postural tremor is predominant.

Essential tremor

Causes: Disturbances in certain areas of the brain, including the cerebellum, are probably behind the disease. The causes have not yet been clarified. It is not uncommon for there to be a familial disposition, which is why the tremor is also called familial tremors. It can already set in in adolescence, but also at an advanced age - and is therefore sometimes referred to as "senile tremor", although it is actually not a "symptom of old age". Most often it starts around forty. Researchers are currently looking for genes that are partly responsible, as twin studies have suggested genetic influences. The essential tremor is actually considered "harmless". However, it can become worse and the tremors can increasingly be perceived as bothersome or obstructive.
Symptoms: There is predominantly a postural tremor. In about half of those affected, there is also an action tremor, which can be very obstructive. Resting tremors are less common. Both hands are most commonly affected, and the head, voice, both legs and trunk are also affected, with decreasing frequency. For many people, the symptom improves when they drink alcohol. This effect can be extremely disastrous - if it induces a harmful type of "self-therapy" or if the environment incorrectly concludes that an alcohol problem could be the cause. The tremor has usually been around for a long time. Those affected often go to the doctor late when they feel more disturbed by the tremor. Sometimes they also show a slight gait disorder.
Diagnosis: The symptoms alone often point to the diagnosis. The neurologist excludes other forms of tremor clinically as well as through electrophysiological examinations and internal diseases with the help of blood tests, among other things. In addition, there are special laboratory analyzes and imaging procedures for special questions (see for example above: brain function SPECT).
Therapy: Well documented therapy options are available here, for example for hand tremor with an anti-epileptic such as primidone or with a beta blocker or with both. Secondly, drugs such as gabapentin or topiramate are used. Remedies like clonazepam or clozapine are available as a reserve. If an essential tremor is very severe and cannot be improved with medication, so-called deep brain stimulation may be an option. Neurosurgeons use a complex surgical procedure to insert electrodes from the outside deep into a specific area of ​​the brain (diencephalon). The other end of the electrodes is connected to a pacemaker under the skin. With weak electrical impulses, nerve cells in the brain can be stimulated and thus also inhibited via the pacemaker. The tremor can be suppressed with it.

When the head is shaking, effects are ascribed to beta blockers such as propranolol and, if necessary, to deep brain stimulation. Voice tremor is more often amenable to direct topical injections of botulinum toxin. All of these treatments require special experience.

Doctors differentiate the so-called FXTAS or Fragile-X-associated tremor-ataxia syndrome from essential tremor. Behind this is a hereditary disease linked to the female sex chromosome X (women have two, men have one). It is more likely to be seen in older men and less often in women. This leads to pronounced action tremor and a disorder of movement coordination with uncontrolled and excessive movements (cerebellar ataxia).

Tremors in Parkinson's syndromes

The term Parkinson's syndrome summarizes the different forms of Parkinson's, of which there are four main groups, as a generic term.
Symptoms: A resting tremor on one side of the body, more likely above 4 Hertz, occurs quite frequently in Parkinson's disease. This so-called Type I Parkinson's Tremor is also characterized by the fact that it lies down when the person concerned makes a holding or other movement.
However, other forms of tremors can also occur as part of the disease. This is how the Type II Parkinson's Tremor from both a resting and a holding tremor, with a frequency difference of more than 1.5 Hertz. Above all, the postural tumor often proves to be very disabling for those affected. Type III Parkinson's Tremor is a pure holding and action tremor, i.e. the opposite of type I, often with a frequency above 5 Hertz.Other symptoms of Parkinson's disease are varied. For example, a noticeable motor slowdown (so-called bradykinesia) or instability in movements due to disruption of certain reflexes can occur, as well as muscle stiffness.
Therapy: An important goal of treatment is to make messenger substances in the brain, especially dopamine, more available again. There are also preparations such as L-Dopa, a precursor of dopamine, or so-called dopamine agonists, which increase the effect of the dopamine present (dopaminergic substances). In the second step, doctors tackle any remaining tremor with so-called anticholinergics, for example. If Parkinson's tremors are unresponsive to medication, deep brain stimulation is an option.

You can read more about the symptoms, causes, diagnosis and treatment of Parkinson's disease in the Parkinson's Guide.

Attention: The doctor uses therapies against tremor very individually for each affected person, of course also taking into account the contraindications. It is always important to treat a possible underlying disease.

What actually is muscle twitching?

Usually benign, short-term twitches, so-called benign fasciculations, often occur in individual muscles on the leg. They are mostly unrhythmic, therefore by definition no Tremor, visible under the skin and not leading to movement. Sometimes they are associated with muscle pain, tingling in the legs, and leg cramps (called pain-fasciculation syndrome). The arms are rarely involved. Muscular exertion can be reinforcing. The symptoms usually subside in rest and relaxation. Neurological controls usually show that the symptoms remain unchanged for a long time. A pathological development is very rare.

As a so-called vegetative disorder, some stressed people sometimes feel a vibration-like twitch of the eyelid, just as trembling can be a "motor expression" of excessive tension.

Lid flutter sometimes occurs in connection with a so-called voluntary nystagmus. This usually results in horizontal, very rapid pendulum movements of both eyes. As the name suggests, these movements can be triggered arbitrarily, for example when the eyes fixate on a nearby object. The termination takes place after about 30 seconds, usually with facial movements and closing the eyelids. The "voluntary nystagmus" is rare and not pathological; but there is obviously a predisposition to it. Sometimes it should be observed in students (exhausted after hours of study?). The neurologist can possibly follow the arbitrary "eye tremors" during an orienting examination of the eyes.

See a doctor, such as a neurologist, if you notice abnormalities such as tremors or muscle twitching. Only if the careful questioning of the complaints and the physical or neurological examination should give clues to a pathological cause, an in-depth diagnosis will follow.

Technical literature for this guide:

Bötzel K, Tronnier V, Gasser T: Differential diagnosis and therapy of tremors. Dtsch Arztebl Int 2014; 111: 225-36. DOI: 10.3238 / arztebl.2014.0225

German Society for Neurology (DGN) e. V .: Extrapyramidal motor disorders: tremor. Guideline S1, September 2012. Online: ( Called on July 29, 2013)

Mattle H, Mumenthaler M: Neurology. Stuttgart Thieme Verlag, 2013

Thömke F: Eye movement disorders. Stuttgart Thieme Verlag, 2008

Herold G and colleagues: Internal Medicine, 2013

Important: This article contains general information only and should not be used for self-diagnosis or self-treatment. He can not substitute a visit at the doctor.

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