Tremor (shaking)

Tremor (shaking) is an involuntary, rhythmic movement of a part of the body – usually the hands, less often the head, voice or legs. A fine tremor is part of every human being. The most common pathological form is essential tremor, also called primary tremor: shaking with no other identifiable cause, which increases with age and, for many of those affected, means one thing above all – difficulty with everyday tasks such as writing, drinking or eating.

What kinds of tremor are there?

Neurological guidance distinguishes between physiological tremor, which underlies every movement and is normally barely visible, and pathological tremor.

• Enhanced physiological tremor: nervousness, cold, exhaustion, a lot of coffee, an overactive thyroid or certain medicines can make normal shaking clearly visible. If it has only been present for weeks or months, it usually has a treatable cause.
• Essential (primary) tremor: shaking of both hands and arms when holding a posture and during movement, present for at least three years, with no other condition found to be the cause.
• Tremor in other conditions: for example in Parkinson’s disease (typically shaking at rest), after injuries or circulatory disorders of the brain, or with metabolic disorders.

How common is essential tremor?

It is the most common movement disorder in adults. A worldwide analysis of many studies (Louis & Ferreira 2010) estimates that almost 1% of the population is affected, and about 4.6% of people over 65. According to the German neurological guideline, more than 30% of people over 80 show a pathological tremor. In many cases parents or siblings already had a tremor – the guideline reports a family history in 40–70% of patients.

When should a tremor be checked by a doctor?

A tremor should be checked by a doctor if it

• is new or clearly getting worse,
• affects only one side of the body or occurs at rest,
• comes with other symptoms (e.g. unsteady gait, slowness, palpitations, weight loss),
• limits daily life – when writing, drinking, eating or at work.

The first point of contact is usually your GP or family doctor; for a precise assessment, a neurologist. What matters is finding treatable causes and distinguishing essential tremor from other conditions.

Which treatments does the guideline describe?

The guideline of the German Society of Neurology (DGN; S2k, 2022) – one example of current clinical guidance – describes a stepwise approach for essential tremor. Which treatment suits an individual is decided by the specialist together with the person concerned.

1. Medication: propranolol and primidone (the latter outside its original licence), as well as topiramate. They reduce the tremor in some of those affected, often not completely, and have side effects that a doctor weighs up.
2. Deep brain stimulation: for severely affected people whose medication does not help enough, the guideline says it should be offered. Electrodes are placed in the thalamus and controlled by a pulse generator; the procedure can be adjusted and is reversible.
3. Focused ultrasound (MRgFUS): for people with essential tremor that does not respond to medication, the guideline says one-sided treatment should be offered if improving one side can improve quality of life. Treatment of both sides should, for now, only take place within studies.

And cannabis? Some people with tremor report that cannabis eases their shaking or the tension that comes with it – experiences differ from person to person. In controlled studies, an improvement has not been measurable so far: in essential tremor, a small placebo-controlled study of THC and CBD found no effect (Longardner et al. 2025, only six participants analysed, so preliminary), and neither did a single dose of CBD. For tremor in multiple sclerosis, the German neurological guideline advises against THC; it attributes the slightly better perceived effect most likely to the substance’s psychological effect. Whether cannabis-based medicines are permitted, and on what terms, differs from country to country – anyone considering them should discuss this with their doctor, not least because of interactions with other medicines and fitness to drive.

Among people close to us, we know of a case in which a THC-dominant preparation prescribed by a doctor noticeably eases the symptoms. It was found only after several preparations and doses had been tried under medical supervision – for this person, one of them works clearly best. This is a single experience, not evidence and not a recommendation. It does show, however, why it can be worth raising the question with the treating doctor, and that the response can be highly individual.

How does focused ultrasound work?

The person lies awake in an MRI scanner wearing a helmet with more than a thousand ultrasound sources. Their waves are focused on a point a few millimetres in size in the thalamus, a relay station for the signals that cause the tremor. First the point is only warmed slightly to check whether the shaking eases; then the tissue there is switched off in a targeted and permanent way. There is no incision and no implant – but, unlike deep brain stimulation, the change in the brain cannot be reversed.

What the evidence shows: in the controlled study by Elias and colleagues (New England Journal of Medicine, 2016) with 76 participants for whom at least two medicines had not helped enough, the hand-tremor score fell from 18.1 to 9.6 points after three months; in the comparison group with a sham procedure it remained almost unchanged (16.0 to 15.8). The improvement was maintained at twelve months. Common side effects were unsteady gait (36%) and tingling or numbness (38%); after one year these persisted in 9% and 14% of those treated, respectively. The study was funded in part by the device manufacturer.

An assessment from Germany: Germany’s Federal Joint Committee (G-BA), which decides on coverage by statutory health insurance there, concluded in 2021 that the benefit is sufficiently proven for people with medication-resistant essential tremor for whom deep brain stimulation is not an option. For people who could also receive deep brain stimulation, a comparison of the two methods has not yet been sufficiently established.

Where is it offered? The procedure is available at individual centres – in Germany, for example, at Freiburg University Hospital since May 2025; Berlin’s Charité has announced a start in 2027 (as of October 2026). Availability and coverage of costs differ from country to country; they are best clarified with a neurologist or the treating centre.

How do other countries approach tremor?

In principle, recommendations around the world agree: medication comes first – propranolol and primidone are first-line everywhere – and a procedure is considered only once at least two medicines have not helped enough. In its 2019 review, the International Parkinson and Movement Disorder Society (MDS) rates one-sided deep brain stimulation, thalamotomy and focused ultrasound as “possibly useful”; for tremor of the head and voice, it considers the evidence insufficient.

The differences lie mainly in when which procedure is an option and who pays for it:

• France: the national health authority HAS assessed one-sided focused ultrasound in 2024. According to that assessment, it is an option not only when deep brain stimulation is ruled out but also – after a shared decision between doctor and patient – when someone prefers a route without surgery; treatment is limited to specialised centres and requires a mandatory registry.
• United Kingdom: NHS England funds deep brain stimulation, thalamotomy and focused ultrasound. Under a policy from July 2026, one-sided radiosurgery (Gamma Knife) is added as a further step for people for whom neither deep brain stimulation nor focused ultrasound is suitable. In 2019 the MDS still considered the evidence for it insufficient.
• United States: the Food and Drug Administration (FDA) approved focused ultrasound for one side of the body in 2016 and for the second side in 2022 – at least nine months apart.
• Spain: an assessment report for the Ministry of Health (2026) considers one-sided focused ultrasound effective, though on low-quality evidence; it acts less strongly than deep brain stimulation and is an option for people for whom an invasive procedure is not possible.
• Other countries: according to manufacturers and the specialist press, focused ultrasound is also offered in Japan, Australia, Canada, Israel, Italy and Poland, among others; whether and how costs are covered varies – in Italy, for example, by region.

On cannabis, by contrast, there is no difference: none of the guidelines reviewed here recommends cannabinoids for tremor. And everywhere the same applies: which route is right in an individual case is for a neurologist to decide.

How does Traditional Chinese Medicine view tremor?

In Traditional Chinese Medicine (TCM), tremor is called 颤证 – “tremor syndrome”. The basic formula comes from the Huangdi Neijing, “The Yellow Emperor’s Inner Classic”: “诸风掉眩，皆属于肝” – everything that sways, shakes and causes dizziness belongs to “wind” and therefore to the liver. Tremor is understood as “liver wind stirring internally” (肝风内动): the sinews and vessels are no longer sufficiently nourished, and the root is usually a deficiency – for example of liver blood, of the yin of liver and kidney, or of qi and blood.

TCM distinguishes several patterns, among them rising “wind-yang” with irritability and dizziness, a deficiency of qi and blood with exhaustion, or a weakness in old age with forgetfulness. Treatment follows the pattern, using herbal formulas and acupuncture.

This is an independent way of seeing that has developed over more than two thousand years and stands alongside modern neurology – with its own view of the human being. There are so far only a few small studies on how effective these treatments are for tremor; this entry makes no statement on that. A tremor that persists or increases should be assessed by a neurologist.

What helps in everyday life?

Many people find their own ways of living with tremor: heavier cups and cutlery, drinking straws, writing with thicker pens, a keyboard instead of handwriting. Occupational therapy can work out such aids in a targeted way.

Our view: nervousness and tension often make shaking worse – anyone who has had to hold a cup or sign their name in front of others knows this. Quiet moments, meditation or autogenic training can help to approach such situations more calmly. This is a suggestion for dealing with stress, not a treatment for tremor – it replaces neither a medical assessment nor therapy. More on growing older and the changes it brings under Ageing, and on complaints concerning the nervous system under Nerve problems.

Note: This article renders a personal, worldview-based view and is not medical advice. It replaces no medical diagnosis or treatment. For health questions please turn to a doctor or pharmacy; do not discontinue prescribed medication on your own initiative.

More from Kyborg Institute in Google Search — Set as preferred source↗

By Tobias O. R. Alke