From the Guidelines
Cephalic no-no tremor is primarily caused by cerebellar dysfunction, with the main aetiologies including multiple sclerosis, cerebellar stroke, cerebellar tumors, spinocerebellar ataxias, essential tremor, Wilson's disease, drug toxicity, alcohol-related cerebellar degeneration, and neurodegenerative disorders like progressive supranuclear palsy. The aetiologies of cephalic no-no tremor, also known as titubation, are diverse and primarily related to cerebellar dysfunction or damage to its connections. Some of the key causes include:
- Multiple sclerosis
- Cerebellar stroke
- Cerebellar tumors
- Spinocerebellar ataxias
- Essential tremor, for which beta-blockers like propranolol have been used as treatment for over 40 years, as noted in a 2022 study published in Hypertension 1
- Wilson's disease
- Drug toxicity, particularly from anticonvulsants like phenytoin
- Alcohol-related cerebellar degeneration
- Neurodegenerative disorders like progressive supranuclear palsy Less common causes include Chiari malformation, paraneoplastic cerebellar degeneration, and metabolic disorders such as hypothyroidism. This side-to-side head tremor results from damage to the cerebellum or its connections, disrupting the normal coordination of head movements. The cerebellum normally functions as a movement regulator, and when damaged, it cannot properly coordinate the opposing muscle groups that stabilize the head, resulting in the characteristic "no-no" oscillatory movement. Diagnosis typically requires neuroimaging (MRI) to identify structural causes, along with laboratory tests to rule out metabolic and toxic causes. Treatment focuses on addressing the underlying condition rather than the tremor itself, though symptomatic management with medications like clonazepam or propranolol may provide some relief in certain cases.
From the Research
Aetiologies of Cephalic No-No Tremor
- The aetiology of cephalic no-no tremor is not fully understood, but research suggests it may be related to essential tremor (ET) 2.
- A study of 51 ET cases with head tremor found that 14 cases (27.5%) had "no-no" tremor, which was often infrequent and became more frequent and acquired additional directionality as the disease progressed 2.
- Another study found that head tremor in ET is more common in women and often resolves when the patient is supine 3.
- The pathophysiology of dystonic tremors, which may be related to cephalic no-no tremor, is thought to involve alterations in the cerebellum and its connections 4, 5.
- A study comparing essential tremor and dystonic tremor found that dystonic tremor exhibited higher variability of peak frequency and greater instability of tremor burst intervals over time, and that cerebellar inhibition was significantly reduced in dystonic tremor 5.
Clinical Features
- Cephalic no-no tremor is often characterized by a "no-no" or side-to-side movement of the head 2.
- The tremor may be infrequent and become more frequent over time, and may acquire additional directionality as the disease progresses 2.
- Head tremor in ET is often associated with arm tremor, and may be more common in women 3.
- The tremor may resolve when the patient is supine, and patients may be unaware of the tremor 3.
Diagnosis and Management
- The diagnosis of cephalic no-no tremor is often based on clinical examination and history, and may involve distinguishing it from other types of tremor such as dystonic tremor 6, 5.
- Treatment options for essential tremor, which may be effective for cephalic no-no tremor, include propranolol and primidone, as well as deep brain stimulation and magnetic resonance imaging guided high intensity focused ultrasound 6.