From the Guidelines
The workup for bilateral hand tremor begins with a thorough clinical history and physical examination to determine the tremor's characteristics and potential causes. Key elements include onset, progression, exacerbating factors, family history, medication use, and alcohol effect on tremor. The neurological examination should assess tremor type (rest, postural, kinetic, or intention), frequency, amplitude, and associated neurological findings.
- Laboratory tests should include:
- Thyroid function tests
- Liver function tests
- Complete blood count
- Comprehensive metabolic panel
- Ceruloplasmin level to rule out Wilson's disease in younger patients
- Additional testing may include:
- Serum glucose
- Calcium
- Drug screens if clinically indicated
- Neuroimaging with MRI of the brain is recommended if there are concerning neurological symptoms or signs suggesting structural lesions.
- Electromyography (EMG) and nerve conduction studies can help differentiate between various tremor types and identify peripheral neuropathies.
- In cases where the diagnosis remains unclear, specialized tests like accelerometry or DaTscan may be considered.
- Referral to a neurologist, particularly one specializing in movement disorders, is appropriate for complex cases or when the diagnosis remains uncertain after initial evaluation, as noted in studies such as 1. This systematic approach helps distinguish between common causes of bilateral hand tremor such as essential tremor, Parkinson's disease, physiologic tremor, medication-induced tremor, and metabolic disorders.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Workup for Bilateral Hand Tremor
The workup for bilateral hand tremor involves a combination of clinical evaluation, electrophysiological studies, and laboratory tests to determine the underlying cause of the tremor.
- Clinical evaluation: A detailed history and physical examination are essential to diagnose and differentiate between various types of tremors 2.
- Electrophysiological studies: Techniques such as accelerometry and electromyography (EMG) can be used to characterize the tremor and differentiate between various tremor syndromes 3.
- Laboratory tests: Laboratory tests such as blood tests and imaging studies may be ordered to rule out secondary causes of tremor, such as thyroid dysfunction or Wilson's disease 4.
Differential Diagnosis
The differential diagnosis of bilateral hand tremor includes:
- Essential tremor: A common cause of action tremor, characterized by a bilateral, symmetric tremor of the hands and arms 5, 6.
- Parkinsonian tremor: A resting tremor that is often asymmetric and associated with other parkinsonian features such as bradykinesia and rigidity 6, 4.
- Dystonic tremor: A tremor that is associated with dystonic posturing or movement 6, 4.
- Physiologic tremor: A normal tremor that is present in everyone, but can be exacerbated by factors such as stress, fatigue, or certain medications 6, 4.
- Drug-induced tremor: A tremor that is caused by certain medications, such as beta-adrenergic agonists or antidepressants 6, 4.
Diagnostic Approach
The diagnostic approach to bilateral hand tremor involves:
- A detailed history and physical examination to characterize the tremor and identify any associated features or symptoms 2.
- Electrophysiological studies, such as accelerometry and EMG, to characterize the tremor and differentiate between various tremor syndromes 3.
- Laboratory tests, such as blood tests and imaging studies, to rule out secondary causes of tremor 4.
- A trial of therapy, such as beta blockers or primidone, to assess the response to treatment and help establish a diagnosis 5, 6.