Head tremor treatment: every option, step by step

Step 1 — Confirm the type of tremor

Essential, dystonic, isolated and secondary head tremor respond differently to each treatment. A clear diagnosis prevents months of trying treatments that are unlikely to work. See how head tremor is diagnosed.

Step 2 — Lifestyle and supportive measures

• Reduce caffeine and other stimulants
• Sleep and stress management — tremor increases with fatigue, anxiety, anger and excitement
• Physiotherapy for neck strength, posture and pain
• A supportive headrest or high-backed chair for reading and screen work; screens raised to eye level
• Support groups — talking to others with tremor reduces isolation

These measures rarely stop the tremor, but they make it milder and reduce neck pain.

Step 3 — Oral medication

Several medications reduce tremor; your neurologist chooses one based on the type of tremor and your other health conditions. They help some people with head tremor, but the benefit is often partial, and side effects such as tiredness, dizziness or slowed thinking can limit the dose. If two or more appropriate medications have not helped enough, further trials rarely change the picture. There is no medication that works reliably for isolated head tremor.

Step 4 — Botulinum toxin injections

Injections into selected neck muscles reduce the force of the shaking. They are particularly useful in dystonic head tremor ^[1]. The effect builds over one to two weeks and wears off after about three to four months, so injections are repeated. Some people develop neck weakness or swallowing difficulty, and some respond less over time.

Step 5 — Surgery

Deep brain stimulation

DBS places thin electrodes in the tremor circuit and connects them to a small stimulator under the skin of the chest. It is adjustable and reversible, and both sides of the brain are treated — important for head tremor, which is a midline symptom ^[4],[5]. At our center the stimulator is switched on the day after surgery. After a successful operation, head tremor usually stops almost as soon as stimulation begins; some centers wait about two weeks before the first switch-on. See DBS for head tremor.

Lesioning

Lesioning (thalamotomy, including focused ultrasound) creates a permanent small lesion in the tremor circuit. It is used mainly for hand tremor on one side; treating both sides — which head tremor usually needs — carries a higher risk of speech and balance problems, and a lesion cannot be adjusted or reversed if the tremor returns or new symptoms appear ^[4]. At our center lesioning is not used unless DBS is not possible for medical reasons.

Comparing the options

When to consider DBS

• The tremor limits work, eating, reading or social life
• Medication and/or injections have not helped enough or cause side effects
• You are in good general health for surgery
• You understand what DBS can and cannot do

Results to expect from DBS

In Prof. YILMAZ’s peer-reviewed series of 22 patients with rare tremor syndromes treated with double-target Vim+PSA DBS, the mean tremor reduction was 89% (range 50–100%), and 6 of 7 patients with isolated head tremor had a tremor score of 0 at 12 months, as rated blindly by two movement disorder specialists ^[6]. In our own case series of patients treated with DBS for head tremor, average improvement was 87%, and more than 70% of patients reached near-complete resolution (our case series; results vary). Our longest-followed head tremor patient still has a tremor score of 0 six and a half years after double-target DBS; the score was 4 before surgery (our case series; results vary).

Cost of surgery

An all-inclusive DBS package at our center typically ranges between USD 30,000 and USD 45,000, depending on the package and the type of device selected. The final figure is confirmed after your evaluation. See international patients.

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