Holmes tremor

Holmes tremor is a slow, coarse tremor that appears after damage to the brainstem, thalamus or cerebellar pathways — for example after a stroke, a bleed, a head injury or multiple sclerosis. It is present at rest, when holding a posture and during movement, and it can involve the head, arm and trunk ^[1],[2]. Medication rarely controls it. In our published series, patients with Holmes tremor had an 80% average reduction in tremor scores after double-target Vim+PSA DBS ^[2].

Key facts

Holmes tremor is a slow, coarse tremor after damage to the midbrain, thalamus or cerebellar pathways ^[1].
It typically appears weeks to months after a stroke, bleed, injury or multiple sclerosis lesion.
Medication rarely controls it.
In our published series, Holmes tremor improved by 80% on average after double-target DBS ^[2].
All four patients with post-traumatic Holmes tremor reached a tremor score of 0 ^[2].

Typical features

Slow tremor — usually below about 5 beats per second
Present at rest, with posture and during movement
Starts weeks to months — sometimes up to two years — after the brain injury
Usually on one side, often with weakness or poor coordination
Large amplitude, often involving the shoulder and upper arm as well as the hand

Causes

Stroke or bleeding in the midbrain or thalamus
Traumatic brain injury
Multiple sclerosis — tremor develops in 25–58% of people with multiple sclerosis ^[2]
Tumors or other lesions affecting the cerebellar pathways

Why it is difficult to treat

Holmes tremor involves several circuits at once, and surgical attempts to relieve it have often failed in the short or long term when a single target was used ^[2]. This is why combining targets can help.

Results in our published series

Eight patients had Holmes tremor caused by multiple sclerosis, cerebellar injury or trauma. The mean tremor score fell from 3.87 to 0.75 (80% improvement). Four patients improved completely (from 4 to 0) and two others from 3 to 0; the remaining two, both after cerebellar injury, improved by 50%. In one of these, no trajectory could pass through both targets, so only the PSA was stimulated ^[2].

See DBS for Holmes and secondary tremor.

Living with Holmes tremor

Occupational therapy for eating, dressing and writing
Weighted utensils and stabilizing aids for the affected arm
Physiotherapy for balance and shoulder control
Treatment of the underlying condition, such as multiple sclerosis

Patient videos

**Holmes Tremor Before & After DBS: A Recovery in Istanbul** — A patient with Holmes tremor before and after deep brain stimulation in Istanbul.
Shared with the patient’s written consent. Individual results vary.

**Holmes Tremor & Essential Tremor: DBS Off vs. On** — Stimulation switched off and on: the effect of DBS in Holmes tremor and essential tremor.
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.

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 ^[2].

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

Frequently asked questions

Why did my tremor start months after the stroke or injury?

The delay is typical of Holmes tremor and reflects slow changes in the damaged brain circuits after the injury.

Can DBS help Holmes tremor after a head injury?

Yes, in selected patients. In our series, all four patients whose Holmes tremor followed trauma reached a tremor score of 0 ^[2].

Is Holmes tremor permanent?

It usually persists without treatment. DBS can reduce it substantially in selected patients ^[2].

Sources

Bhatia KP, et al. Consensus Statement on the classification of tremors from the task force on tremor of the International Parkinson and Movement Disorder Society. Mov Disord 2018. utsouthwestern.elsevierpure.com/en/publications/consensus-statement-on-the-classification-of-tremors-from-the-tas
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/