What causes tremors upon waking?

Morning Tremors: Causes and Management

Morning tremors upon waking are most commonly due to physiologic tremor exacerbated by factors such as low blood sugar, dehydration, temperature changes, or withdrawal from medications or substances.

Types of Morning Tremors

Physiologic Tremor

• Most common cause of morning tremors
• Characterized by fine, rapid oscillations (8-12 Hz)
• Typically resolves shortly after waking
• Exacerbated by:
  • Hypoglycemia (low blood sugar after overnight fast)
  • Dehydration
  • Temperature changes (being cold upon waking)
  • Caffeine withdrawal
  • Medication withdrawal (especially sedatives)
  • Anxiety or stress

Orthostatic Tremor

• May occur when standing up after waking
• Diagnostic criteria include:
  • Heart rate increase ≥30 bpm (≥40 bpm in 12-19 year-olds) within 10 minutes of standing
  • Absence of orthostatic hypotension
  • Symptoms of orthostatic intolerance 1
• Often accompanied by dizziness, lightheadedness, or weakness upon standing

Withdrawal Tremors

• Can occur in the morning due to overnight withdrawal from:
  • Alcohol
  • Benzodiazepines
  • Certain antidepressants
  • Beta-blockers
• Usually more pronounced than physiologic tremor

Differential Diagnosis

Essential Tremor

• Action tremor that may be worse in the morning
• Typically bilateral, affecting hands primarily
• May improve after movement or with small amounts of alcohol
• Family history often present

Parkinsonian Tremor

• Resting tremor that disappears with movement 2
• Usually asymmetric
• Often accompanied by rigidity and bradykinesia
• Less likely to be exclusively a morning phenomenon

Metabolic Causes

• Hypoglycemia (most common metabolic cause of morning tremor)
• Thyroid disorders (particularly hyperthyroidism)
• Electrolyte imbalances

Evaluation and Management

Self-Assessment Questions

1. Is the tremor only present in the morning?
2. Does it resolve after eating, hydrating, or warming up?
3. Is it associated with medication use or substance intake/withdrawal?
4. Are there other neurological symptoms?

Management Strategies

For Physiologic Morning Tremor:

• Ensure adequate hydration before bed and upon waking
• Maintain stable blood sugar with a small protein-containing snack before bed
• Gradually taper caffeine consumption rather than abrupt cessation
• Keep room temperature comfortable

For Medication-Related Tremor:

• Review medication timing with healthcare provider
• Consider adjusting dosing schedule to prevent withdrawal effects
• Never stop prescribed medications without medical consultation

For Orthostatic Tremor:

• Rise slowly from bed in stages
• Increase fluid intake (2-3 liters daily) and salt intake (10-12g daily) unless contraindicated 1
• Consider compression garments if symptoms persist 1

When to Seek Medical Attention

Urgent Evaluation Needed If:

• Tremor is severe or disabling
• Tremor is accompanied by other neurological symptoms
• Tremor persists throughout the day
• Tremor is associated with:
  • Confusion or altered mental status
  • Difficulty speaking or swallowing
  • Loss of coordination
  • Weakness on one side of the body

Conclusion

Morning tremors are typically benign and related to physiologic factors that resolve with simple interventions. However, persistent tremors or those accompanied by other neurological symptoms warrant medical evaluation to rule out underlying neurological disorders.