Tremor in Multiple Sclerosis: Causes, Diagnosis and Treatment
Tremor in multiple sclerosis is most often related to dysfunction of the cerebello-thalamo-cortical pathways and frequently coexists with ataxia, impaired movement accuracy and balance problems. Effective treatment requires assessment not only of tremor severity, but also of its type, its impact on hand function and the contribution of other neurological deficits.
According to a 2025 systematic review, the pooled frequency of tremor in people with MS was approximately 33%, although estimates varied substantially between studies. In larger cohorts, prevalence was closer to 22%.
Why tremor occurs in multiple sclerosis
The most characteristic tremor in MS is related to dysfunction of the cerebello-thalamo-cortical network responsible for the accuracy and smoothness of movement.
Cerebellum
Demyelinating lesions and atrophic changes can disrupt real-time correction of movement.
Thalamus
The thalamus participates in transmission and integration of motor signals. Its involvement may amplify pathological oscillations.
Connections between structures
Not only individual lesions matter, but also damage to pathways connecting the cerebellum, thalamus and motor cortex.
What types of tremor occur in MS
Intention tremor
Becomes more pronounced as the hand approaches a target: during finger-to-nose testing, writing, using cutlery or working with small objects.
This is the most characteristic type of tremor associated with cerebellar dysfunction.
Postural tremor
Appears or increases when the patient holds the arm in a certain position. It may coexist with an intention component.
Rest tremor
It is not typical of classic cerebellar tremor in MS. If prominent, parkinsonism or another additional cause should be considered.
Tremor and ataxia are not the same thing
People with MS may simultaneously have tremor, dysmetria, impaired coordination, weakness and sensory ataxia. Even when tremor itself is reduced, hand function may remain limited because of other components of the cerebellar syndrome.
Not every tremor in a person with MS is caused by multiple sclerosis
Essential tremor
Usually bilateral and predominantly postural and kinetic. A family history may be present. Other cerebellar or focal neurological signs may be absent.
Parkinsonian tremor
Usually more prominent at rest, may be asymmetric and can coexist with bradykinesia, rigidity and characteristic movement changes.
Functional tremor
Typical features include variability, change with distraction, entrainment and other positive signs of a functional movement disorder.
Medication-related and metabolic causes
Tremor may worsen with thyrotoxicosis, hypoglycemia and certain medications, including stimulants, lithium, valproate and some antidepressants.
What a neurologist evaluates in a patient with tremor
Type and circumstances
It is important to determine whether tremor appears at rest, while maintaining posture, during movement or as the hand approaches a target.
Associated neurological deficits
Ataxia, dysmetria, weakness, sensory function, speech, gait and balance are assessed.
MRI
When necessary, MRI is reviewed for involvement of the cerebellum, brainstem, thalamus and related pathways, as well as the overall activity of MS.
Quantitative assessment
The Bain scale, video recording, handwriting analysis, Archimedes spiral, accelerometry and performance of specific everyday tasks may be used.
Treatment of tremor in multiple sclerosis
There is currently no universal medication that reliably controls cerebellar tremor in MS. In practice, treatment is built around the patient's functional goal and often combines several approaches.
| Approach | When it may be useful | Limitations |
|---|---|---|
| Propranolol | May be useful when there is a prominent postural component. | The effect on typical cerebellar tremor in MS is often limited. |
| Clonazepam | Sometimes reduces tremor severity in selected patients. | Sedation, falls, cognitive effects and risk of dependence limit long-term use. |
| Levetiracetam and other antiseizure medications | Sometimes used individually in refractory tremor. | Study results are inconsistent and convincing evidence is lacking. |
| Cannabinoids | May be used for other MS symptoms when appropriate. | Controlled studies have not shown a reliable effect specifically on tremor. |
| Botulinum toxin type A | May be considered for severe upper-limb tremor when the muscles generating the pathological movement can be identified. | Requires individualized muscle selection and dosing. The main risk is excessive weakness. |
Botulinum toxin therapy for hand tremor
Botulinum toxin does not treat multiple sclerosis itself, but in carefully selected patients it may reduce tremor amplitude and improve performance of specific hand tasks.
When this approach is particularly logical
When tremor is generated by a relatively limited set of muscles and the pathological movement can be reduced without taking away useful residual strength.
Main limitation
If the dose is too high or the wrong muscles are selected, weakness can impair hand function more than the original tremor.
What studies have shown
In a randomized trial, botulinum toxin type A injections improved tremor severity, handwriting and spiral drawing compared with placebo. At the same time, post-injection weakness was substantially more frequent, so the outcome depends greatly on accurate muscle selection and dosing.
How to reduce the impact of tremor on everyday life
Trunk and shoulder-girdle stabilization
Better proximal stability may sometimes improve control of hand and forearm movement.
Occupational therapy
Writing, eating, computer use, household tasks and workplace setup can be adapted.
Weighting and stabilization
Wrist weights, orthoses and specialized devices may sometimes reduce the functional consequences of tremor, although the effect is individual.
Specialized cutlery
Thickened handles, stabilizing spoons and other devices can improve independence during meals.
Balance and gait
When tremor coexists with ataxia, balance and fall prevention should be addressed separately.
Local cooling
In some patients it can temporarily reduce tremor amplitude and may be useful before a specific functional task.
When conventional treatment is not enough
Active orthoses and stabilizing devices
Systems are being developed that detect pathological movement and mechanically or electronically reduce its amplitude. Evidence specifically for MS tremor remains limited.
MRgFUS
Focused ultrasound has been widely studied in essential and some other tremor syndromes. Experience in MS-related tremor remains limited, so it cannot be considered standard therapy.
Deep brain stimulation for severe MS tremor
DBS may be considered in very carefully selected patients with severe tremor that markedly limits function and does not respond to medication and rehabilitation.
Possible benefit
In a systematic review and meta-analysis of 17 studies including 168 patients, tremor improvement after DBS was reported in approximately 73%.
However, study results were highly heterogeneous, and most evidence did not come from large contemporary randomized trials.
Why function may improve less than tremor
Even when tremor is substantially reduced, persistent ataxia, dysmetria, weakness or sensory deficits may still limit functional improvement.
Can MS tremor be completely eliminated?
Complete disappearance of severe cerebellar tremor is uncommon. The practical goal is to reduce its impact on specific functions and preserve as much independence as possible.
Eating and drinking
Hold a cup, use a spoon and fork, and reduce spilling.
Writing and phone use
Improve accuracy when writing, typing and using a touchscreen.
Self-care
Make dressing, personal hygiene and other everyday activities easier.
When a separate tremor assessment may be useful
Tremor interferes with hand function
It is important to determine what limits movement most: tremor itself, ataxia, weakness or a combination of these factors.
Medication does not help
The tremor diagnosis, rationale for current medications and possibilities of botulinum toxin therapy or rehabilitation can be reassessed.
DBS is being considered
It is important to estimate in advance whether reducing tremor is likely to produce meaningful functional improvement.
The tremor has changed
New rest tremor, marked asymmetry or rapid worsening require renewed differential diagnosis.
Consultation with Dr. Lidiia Prakhova
In a person with multiple sclerosis and tremor, the type and mechanism of tremor can be assessed together with its relationship to other neurological deficits and the potential role of medication, botulinum toxin therapy, rehabilitation and neuromodulation approaches.
Frequently asked questions about tremor in MS
Why does tremor become worse as the hand approaches an object?
Does propranolol help MS tremor?
Can botulinum toxin be used?
Do cannabinoids help tremor?
Can DBS help MS tremor?
Does new tremor always mean an MS relapse?
Key scientific references
- Vaheb S, Dehghani Firouzabadi D, Ghoshouni H, et al. Frequency of tremor in people with multiple sclerosis: a systematic review and meta-analysis. Clinical Parkinsonism & Related Disorders. 2025;12:100315. doi:10.1016/j.prdoa.2025.100315.
- Boonstra FM, Noffs G, Perera T, et al. Functional neuroplasticity in response to cerebello-thalamic injury underpins the clinical presentation of tremor in multiple sclerosis. Multiple Sclerosis. 2020;26(6):696–705. doi:10.1177/1352458519837706.
- Boonstra F, Florescu G, Evans A, et al. Tremor in multiple sclerosis is associated with cerebello-thalamic pathology. Journal of Neural Transmission. 2017;124(12):1509–1514. doi:10.1007/s00702-017-1798-4.
- Abboud H, Hill E, Siddiqui J, Serra A, Walter B. Neuromodulation in multiple sclerosis. Multiple Sclerosis. 2017;23(13):1663–1676.
- Zali A, Jahanshahi A, Rahimpour S, et al. Deep brain stimulation for multiple sclerosis tremor: a systematic review and meta-analysis. Multiple Sclerosis and Related Disorders. 2021;54:103256. doi:10.1016/j.msard.2021.103256.
- Van der Walt A, Sung S, Spelman T, et al. A double-blind, randomized, controlled study of botulinum toxin type A in MS-related tremor. Neurology. 2012;79(1):92–99. doi:10.1212/WNL.0b013e31825dcdd9.
- Koch M, Mostert J, Heersema D, De Keyser J. Tremor in multiple sclerosis. Journal of Neurology. 2007;254(2):133–145. doi:10.1007/s00415-006-0296-7.
- Ghadiri F, Moghadasi AN. Pharmacological treatment of tremor in multiple sclerosis: a systematic review. Multiple Sclerosis and Related Disorders. 2022.
- Fox P, Bain PG, Glickman S, Carroll C, Zajicek J. The effect of cannabis on tremor in patients with multiple sclerosis. Neurology. 2004;62(7):1105–1109. doi:10.1212/01.WNL.0000118203.67138.3E.
Material updated September 2026.
