DBS for dystonic head tremor

DBS can improve dystonic head tremor, but the choice of target is critical. When dystonia (pulling and abnormal posture) dominates, the globus pallidus internus (GPi) is the usual target; when tremor dominates, thalamic and subthalamic targets are used. Published series report improvement in dystonic head tremor with thalamic and subthalamic stimulation ^[1],[2], while a systematic review notes that results vary between targets and that combinations of targets can give better tremor control ^[3]. In our published double-target series, the tremor was abolished in 3 of 4 patients with dystonic tremor and their dystonia scores improved by 72% ^[4].

Key facts

The target depends on whether dystonia or tremor dominates.
GPi for pulling and posture; Vim+PSA when the shaking dominates.
Blinded study: head tremor amplitude improved 77.5% with thalamic/subthalamic DBS ^[1].
Our series: tremor abolished in 3 of 4 dystonic tremor patients; dystonia scores improved 72% ^[4].
Tremor responds quickly; dystonic pulling improves over weeks to months.

**40 Years of Head Tremor, 3 Years After DBS: Lasting Relief** — A patient with 40 years of head tremor, three years after DBS.
Shared with the patient’s written consent. Individual results vary.

**Head Tremor Before & After DBS: A 43-Year-Old from Uzbekistan** — A 43-year-old patient from Uzbekistan treated for head tremor.
Shared with the patient’s written consent. Individual results vary.

**Progressing Tremor Before & After DBS: A 42-Year-Old from Uzbekistan** — A 42-year-old patient from Uzbekistan treated with DBS for a progressing tremor; an example of “yes-yes” head tremor.
Shared with the patient’s written consent. Individual results vary.

**Head Tremor 5 Years After DBS: Still Free of Shaking** — A head tremor patient five years after deep brain stimulation; an example of “no-no” head tremor.
Shared with the patient’s written consent. Individual results vary.

**Visible Head Tremor Before & After DBS in Turkey** — A patient whose head tremor was visible to everyone, before and after DBS.
Shared with the patient’s written consent. Individual results vary.

Watch many more head tremor patientsOur YouTube playlist: many head tremor patients filmed before and after DBS

Open the head tremor video library on this site.

Choosing the target

Main problem	Usual target
Pulling, twisting, abnormal head posture	GPi
Shaking is the main problem, dystonia mild	Vim + PSA (double target)
Both marked	Planned individually; sometimes more than one target

Stimulation of the Vim alone mainly improves the tremor component of dystonic tremor; some studies have also reported improvement of dystonic symptoms with PSA and thalamic stimulation ^[4]. In a blinded study of thalamic/subthalamic DBS in dystonia with head tremor, head tremor amplitude improved by 77.5% and pain by 90% ^[1]. A long-term series of 18 patients with dystonic head tremor as the leading symptom found thalamic DBS safe and effective with stable results ^[2].

One side or both?

Dystonic tremor is the one situation in which one-sided surgery is sometimes considered — when the neck pulls clearly to one side and the tremor moves in one direction only. Because these conditions tend to progress, we generally recommend treating both sides.

What to expect

The tremor usually responds as soon as the stimulator is switched on the day after surgery
Dystonic pulling improves more gradually, over weeks to months
Some patients no longer need botulinum toxin injections; others need fewer
Neck pain usually lessens

Our published results in dystonic tremor

Four patients with dystonic tremor were treated with double-target DBS. In three, the tremor was completely abolished (score 4 → 0); in the fourth it improved from 4 to 1. Their dystonia motor scores improved from a mean of 18 to 5 (72%) ^[4].

Side effects and how they are handled

Stimulation side effects usually appear when the stimulator is first switched on or when settings are increased, and most disappear when the settings are adjusted. In our published series ^[4]:

Tingling (paresthesia) was the most common effect when stimulation began; it faded within minutes without any change of settings.
Slurred speech appeared in one patient after the first electrode, lasted two weeks and resolved by itself; the second side was operated after it had settled.
Unsteadiness occurred in two patients: in one it resolved by itself, in the other after the active contact was moved slightly upward within the Vim and the PSA share was reduced.

Speech side effects were a known drawback when only the Vim was used. In our experience, the PSA is safer than the Vim with respect to speech, and because both targets sit on the same electrode, we can move stimulation away from a site that causes a problem. A well-placed electrode is the key: if an electrode lies too far to the side, speech effects can persist, which is why placement is checked by testing during surgery and by CT afterward ^[4].

Surgical complications are uncommon but real. In the published series, one electrode needed repositioning and two patients developed an infection requiring removal of an electrode, which was later re-implanted in one of them ^[4]. Your individual risk is discussed during the evaluation.

Your surgeon

Prof. Atilla YILMAZ, MD

Every operation is performed personally by Prof. YILMAZ, a stereotactic and functional neurosurgeon who has carried out 1,200+ neuromodulation procedures, including 800+ DBS surgeries, for patients from 60+ countries. He is the first author of the published double-target Vim+PSA series for rare tremor syndromes ^[4].

President, Middle-Eastern Society for Stereotactic and Functional Neurosurgery (MSSFN); Board of Directors, WSSFN and International Neuromodulation Society
Proctor for Medtronic, Abbott and Boston Scientific — the three leading DBS manufacturers appoint him to train other neurosurgeons on their systems
40+ neurosurgeons trained from 30 countries; first-ever DBS surgeries performed in six countries
Trained at the University of Florida (observership with Prof. Okun and Prof. Foote) and Umeå University Hospital, Sweden

Full profile and credentials

Questions to ask before choosing DBS

What type of tremor do I have, and how sure is the diagnosis?
Which target will be used, and why?
Will both sides be operated on?
Who will perform the operation, and how many tremor operations has the surgeon done?
When will the stimulator be switched on, and who will program it after I go home?
What happens if the effect lessens in the future?

Frequently asked questions

Is GPi or Vim better for dystonic head tremor?

It depends on whether dystonia or tremor is the bigger problem. GPi is preferred when pulling and posture dominate; thalamic or subthalamic targets when the shaking dominates ^[2],[3].

Will I still need botulinum toxin after DBS?

Some patients stop injections completely; others continue with fewer or smaller doses.

How quickly does dystonia improve?

Tremor responds quickly; the pulling and abnormal posture of dystonia usually improve gradually over weeks to months.

Sources

Pauls KA, et al. Deep brain stimulation in the ventrolateral thalamus/subthalamic area in dystonia with head tremor. Mov Disord 2014;29(7):953–960. doi.org/10.1002/mds.25884
Thalamic deep brain stimulation for dystonic head tremor: a long-term study of 18 patients. Mov Disord Clin Pract. onlinelibrary.wiley.com/doi/abs/10.1002/mdc3.70266
Tsuboi T, Au KLK, Deeb W, Almeida L, Foote KD, Okun MS, Ramirez-Zamora A. Motor outcomes and adverse effects of deep brain stimulation for dystonic tremor: a systematic review. experts.umn.edu/en/publications/motor-outcomes-and-adverse-effects-of-deep-brain-stimulation-for-/
Yilmaz A, Eray HA, Cakir M, Ceylan M, Blomstedt P. Deep Brain Stimulation with Double Targeting of the VIM and PSA for the Treatment of Rare Tremor Syndromes. Stereotact Funct Neurosurg 2024;102:224–239. DOI 10.1159/000539162. pubmed.ncbi.nlm.nih.gov/38934181/