Essential tremor (ET) is a movement disorder of unknown etiology. It is also known as hereditary tremor or familial tremor because of its slow progression and benign course. It is one of the most common adult diseases, with an estimated prevalence of 0.4% to 5%, and the prevalence and incidence of ET increases with age, with a prevalence of about 5% in the elderly population over 65 years of age. However, ET can lead to significant somatic and psychosocial disability. The tremor increases in magnitude over time, so difficulties with writing, eating, dressing, speaking and other fine activities worsen. Clinical features 1. postural or motor tremor of the limbs and head, no resting tremor, or even if there is, it is not obvious; 2. no systemic or other neurological diseases related to tremor, no signs of Parkinson’s disease or cerebellar dysfunction; 3. no use of any medications that cause tremor; 4. tremor frequency is often 5-12 Hz; 5. ethanol and beta-adrenergic receptor blockers can control tremor; 6. family history of tremor may be 6. Family history may be positive. The AAN published guidelines for the treatment of idiopathic tremor Treatment is generally with propranolol and paracetamol, although the FDA only approves propranolol for the treatment of ET. it is estimated that at least 30% of ET patients treated with propranolol and paracetamol are ineffective. Ethanol reduces the amplitude of tremor in 50% to 90% of patients, but tremor can temporarily worsen after the effects of ethanol wear off. Invasive treatments (including surgery) are effective in patients with intractable tremor. Propranolol, long-acting propranolol, and paromidone can reduce limb tremor, and the efficacy of propranolol and paromidone is roughly similar; limited data suggest that the efficacy of long-acting propranolol is similar to that of regular propranolol. Recommendation:Propranolol, long-acting propranolol, or paromidone may be used to treat limb tremor (Class A). Alprazolam, atenolol, gabapentin (single agent), sotalol, and topiramate are likely to reduce limb tremor, and limited data suggest that propranolol may reduce head tremor. Recommendations:Atenolol, gabapentin (monotherapy), sotalol, and topiramate may be used to treat limb tremor (Grade B); alprazolam should be used with caution because of the risk of abuse (Grade B). Propranolol may be used to treat head tremor (Grade B) Clonazepam, clozapine, nadolol, and nimodipine may perhaps reduce limb tremor. Recommendations:Nadolol and nimodipine may be considered for limb tremor (Grade C); use clonazepam with caution because of the risk of abuse and the development of withdrawal syndrome (Grade C). Clozapine is recommended only for patients with intractable limb tremor because it can lead to granulocyte deficiency (Grade C). Trazodone does not reduce limb tremor. Recommendation:Trazodone is not recommended for the treatment of limb tremor (Grade A). Acetazolamide, isoniazid and indolol did not reduce limb tremor. Recommendation:Acetazolamide, isoniazid, and indolol are not recommended for the treatment of limb tremor (Grade B). Acetazolamide, mirtazapine, nifedipine, and verapamil do not reduce limb tremor. Recommendation:Acemetazolamide, mirtazapine, nifedipine and verapamil are not recommended for the treatment of limb tremor (Grade C). Is the combination of paracetamol and propranolol more effective than alone? The combination of paracetamol and propranolol may be more effective than monotherapy in reducing limb tremor without an increase in adverse effects. Recommendation:If the efficacy of paracetamol and propranolol alone for limb tremor is unsatisfactory, paracetamol and propranolol may be used in combination (Grade B). Is the efficacy of ET drug therapy durable? In more than half of the patients, the antitremor effect of paracetamol and propranolol is maintained for at least 1 year. Recommendation: Dose may need to be increased when treating limb tremor with paracetamol and propranolol for up to 12 months (Grade C). Problems with paracetamol and propranolol Propranolol is prone to fatigue, muscle weakness, impotence and sleep disorders Interactions with digoxin, calcium antagonists and antiarrhythmic drugs may occur. The metabolite of promethazine is luminal, which can induce the production of metabolites of many drugs (including warfarin) Treatment of botulinum toxin type A or B BTX A reduces limb tremor, but is not very effective, and there are also hand weakness adverse effects that worsen with increasing dose. bTX A also reduces head tremor and voice tremor, but there is little information. bTX A for voice tremor has been associated with wheezing sounds, hoarseness, and BTX A has been associated with adverse effects such as wheezing, hoarseness and dysphagia. Recommendations: Injectable BTX A may be considered for limb, head and voice tremor in patients who have failed medical therapy (Grade C). Surgical treatment of ET Unilateral thalamotomy is effective in the treatment of contralateral limb tremor, while bilateral thalamotomy has an increased incidence of adverse effects, often severe. Recommendation: Unilateral thalamotomy can be used to treat limb tremor that has failed to respond to medication (grade C). Bilateral thalamotomy is not recommended due to the severity of adverse effects. Recommendation: VIM thalamic nucleus DBS can be used to treat limb tremor that has failed to respond to pharmacological treatment (grade C). Both DBS and thalamotomy are effective in suppressing tremor in patients with ET. Recommendation: DBS has fewer adverse effects than thalamotomy (grade B), but the use of DBS or thalamotomy depends on the individual circumstances of each patient, the risk of intraoperative complications, and the ability to supervise and adjust the stimulator Indications for bilateral or unilateral surgery Thalamic DBS suppresses contralateral limb tremor, so bilateral DBS is required in patients with bilateral upper limb tremor. However, there is no evidence that bilateral DBS has a synergistic effect on the suppression of limb tremor. Furthermore, there is insufficient information on the risk/benefit ratio of unilateral DBS versus bilateral DBS. Similarly, there is insufficient information on bilateral DBS for head tremor and voice tremor. Recommendation: Bilateral DBS is required to suppress bilateral upper limb tremor, but there is insufficient information on the risk/benefit ratio of unilateral DBS to bilateral DBS for limb tremor (level U). Similarly, there is no sufficient information to recommend bilateral or bipartite DBS for cephalic tremor and phonatory tremor. Bilateral DBS is associated with more adverse effects, and bilateral thalamotomy is not recommended.