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Isolated vertical head tremor: A diagnostic challenge
*Corresponding author: Daifallah Mohammed Almalki, Department of Internal Medicine, College of Medicine, Prince Sattam bin Abdulaziz University, Al-Kharj, Saudi Arabia, d.almalki@psau.edu.sa
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Received: ,
Accepted: ,
How to cite this article: Almalki DM. Isolated vertical head tremor: A diagnostic challenge. J Neurosci Rural Pract. 2026;17:320-1. doi: 10.25259/JNRP_68_2026
Abstract
Essential tremor (ET) is the most common tremor disorder, typically affecting the upper limbs, while isolated head tremor is uncommon and diagnostically challenging. We report a 56-year-old woman with a more than 30-year history of isolated head tremor without limb or voice involvement. The tremor consisted of vertical ( yes yes ) oscillations, worsened with stress, and was also present at rest. Neurological examination showed no evidence of cervical dystonia. Notably, the patient demonstrated clinical improvement with propranolol. This case supports isolated head tremor as a rare manifestation within the ET spectrum, characterized by long-term stability and therapeutic responsiveness.
Keywords
Case report
Dystonic tremor
Essential tremor
Isolated head tremor
Propranolol
“Yes-yes” tremor
INTRODUCTION
The term “tremor” refers to an involuntary rhythmic oscillatory movement that is the result of alternating or synchronous contractions of reciprocally innervated muscles. The most prevalent tremor disorder is essential tremor (ET), reaching up to 4% of adults and increasing in prevalence with age.[1] ET is classically recognized by upper extremity action tremor, although tremor may also involve the head, voice, and trunk.[2] Head tremor occurs in approximately one-third of ET patients but typically develops after limb involvement.[2] Isolated head tremor without limb tremor is uncommon and presents diagnostic challenges. The Movement Disorder Society consensus criteria 2018 define ET as an isolated tremor syndrome characterized by upper limb action tremor that persists for a minimum of 3 years, with or without tremor in other sites.[3] However, isolated head tremor does not strictly fulfill classic criteria, and it remains debated regarding whether it represents ET, dystonic tremor, or another tremor syndrome. The differentiation between ET and dystonic tremor is particularly important, as dystonic tremor is typically associated with abnormal posture and muscle contraction.[4] Tremor direction may provide supportive clinical clues, although overlap exists between disorders.[5] We present a case of isolated vertical head tremor persisting for more than three decades with propranolol responsiveness and long-term stability, which improves our knowledge of isolated head tremor within the ET spectrum.
CASE REPORT
A 56-year-old woman presented to the neurology clinic seeking a second opinion regarding a long-standing head tremor. The patient reported tremor onset more than 30 years earlier. The tremor involved the head exclusively throughout its course. She denied tremor affecting the upper limbs, lower limbs, voice, or trunk at any time. The tremor followed a stable clinical course without progression in anatomical distribution or significant worsening in severity. The patient reported worsening tremors during periods of emotional distress and anxiety. However, it can present during calm states. She was diagnosed with seropositive rheumatoid arthritis roughly 10 years ago and has been treated with methotrexate. She was also diagnosed with fibromyalgia. No one in the family had ever experienced tremors or movement abnormalities. The patient reported that the tremor caused social discomfort but did not interfere significantly with daily activities. She denied alcohol use. Approximately 20 years earlier, she experienced a neurological evaluation, including magnetic resonance imaging of the brain and thyroid function testing, that turned out to be unremarkable. She was prescribed propranolol at a dose of 40 mg twice daily and reported an estimated more than 50% improvement. However, she did not maintain regular therapy. Importantly, tremor onset preceded the diagnosis of rheumatoid arthritis and initiation of methotrexate therapy by more than 20 years. Neurological examination revealed a rhythmic vertical head tremor characterized by a “yes, yes” pattern. The tremor frequency was estimated at 4–6 Hz. Tremor amplitude was mild to moderate and visually apparent but not functionally disabling; however, precise tremor frequency measurement was not performed. No tremor was observed in the upper limbs, lower limbs, or voice. Examination of the neck revealed no cervical dystonia. There was no abnormal neck posture, sustained muscle contraction, directional pulling, or sensory trick. No null point was identified during examination. The tremor amplitude did not significantly decrease with specific head positioning, and no position-dependent suppression was observed. There were no signs of parkinsonism. Muscle tone, strength, and reflexes were normal. Cerebellar examination and gait were normal.
DISCUSSION
This case describes an uncommon presentation of isolated vertical head tremor persisting for more than three decades without limb involvement. Isolated head tremor has been described as part of the ET spectrum. Louis and Dogu demonstrated that isolated head tremor occurs in a small proportion of ET patients.[5] Long-term stability without development of dystonia, as observed in this case, strongly supports ET. The important differential diagnosis in such a presentation is cervical dystonia. Dystonic tremor is typically associated with abnormal posture, sustained muscle contraction, or sensory tricks.[4] The absence of these features over more than three decades strongly argues against dystonic tremor. Tremor directionality may provide useful diagnostic information, since ET can manifest as vertical (yes-yes), horizontal (no-no), or mixed head tremor patterns, whereas dystonic tremor is more irregular and associated with abnormal posture.[6] The vertical tremor pattern seen in this case, along with the response to propranolol, supports the diagnosis of ET. Tremors that happen as part of a systemic condition or medication-induced are called secondary tremor or enhanced physiological tremor, not primary tremor syndromes like ET.[3,7] Notably, tremor in this case did not begin until over 20 years before methotrexate treatment and that does not even account for medication-induced tremor. ET is now understood to exhibit clinical heterogeneity and a spectrum of disorders involving cerebello-thalamo-cortical dysfunction.[8] Although isolated head tremor has been previously reported, long-term clinical observations remain limited. This example illustrates an isolated head tremor lasting for almost three decades without progression or the emergence of dystonia. It is more likely that the patient has ET due to the demonstrated responsiveness to propranolol and the obvious temporal link, ruling out autoimmune illness and drug side effects.[6] This case provides valuable longitudinal clinical observation over more than three decades, contributing supportive evidence to ongoing discussions regarding isolated head tremor classification.
CONCLUSION
This case describes chronic isolated vertical head tremor with propranolol responsiveness and long-term stability. Clinical features strongly support ET with atypical anatomical distribution.
Acknowledgments:
The author extends its appreciation to the Deputyship of Research and Innovation, Ministry of Education in Saudi Arabia.
Ethical approval:
Institutional Review Board approval is not required.
Declaration of patient consent:
The author certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The author confirms that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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