Question

I understand that a tremor, or shaking in the hands, sometimes occurs in ME/CFS. But it could also be a sign of Parkinson’s disease. I’m in my mid fifties and have had moderate ME/CFS for about five years. It is fairly stable but the tremor, which is in both hands and tends to be more noticeable when I’m fatigued, has only been present for a few weeks. Should I see my GP?

Answer

There is a long list of possible causes of tremor in the hands. Tremor can be inherited, where it sometimes affects quite young adults, and is known as essential tremor. This also affects about 4% of adults over the age of 40. Tremor can occur in neurological conditions such as Parkinson’s disease and multiple sclerosis, and medical conditions such as hypoglycaemia (low blood sugar) and hyperthyroidism (an overactive thyroid gland). A number of drugs can cause tremor as a side effect, for example, metoclopramide (for nausea and migraine) and salbutamol (for asthma).

Clues about the cause of tremor include:

• having a family history of tremor (essential tremor),
• factors which exacerbate tremor. Common ones being anxiety, alcohol, caffeine intake,
• when the tremor occurs at rest (as in Parkinson’s disease) or when moving towards an object (an intention tremor).
• where in the body it occurs – hands, head or neck. If a tremor affects the voice box it can cause a shaky voice.

Fatigue is a very common exacerbating factor for tremor, which helps to explain why it is sometimes reported by people with ME/CFS. If a tremor is associated with any of the following ‘red flag’ signs – sudden onset, progressively getting worse, age under 50 with no family history of essential tremor – this suggests a medical cause.

In Parkinson’s disease there may also be a characteristic change in the way someone walks – a shuffling gait – and what is called ‘cogwheel rigidity' in the limbs (a jerky feeling in your arm or leg that you can sense when moving or rotating the affected limb or joint). You will need to see your doctor – who will take a full history, examine your tremor and your nervous system, arrange a few investigations, and refer you to a neurologist if further assessment is required in order to confirm the cause and make a diagnosis.

Treatment will depend on the cause. Reducing any exacerbating factors – alcohol, caffeine, fatigue, stress – is obviously important if no specific cause is found. There are no simple drug solutions for a tremor that is associated with ME/CFS. However, drugs called beta-blockers can sometimes help with an essential tremor.

The NHS: Tremor or shaking hands | November 2020

When a tremor is normal

It's normal to have a slight tremor. For example, if you hold your hands or arms out in front of you, they will not be completely still. Sometimes a tremor becomes more noticeable. This often happens:

• • as you get older
  • when you're stressed, tired, anxious or angry
  • after drinking caffeine (for example, in tea, coffee or cola) or smoking
  • if you're very hot or cold

See a GP if you have a tremor or shaking hands and it's getting worse over time and/or it's affecting your daily activities. Your doctor will want to make sure the tremor is not caused by another condition. They may also be able to offer treatment.