My head shakes: is it dystonia?

Many people with dystonia experience head shake especially if the dystonia is affecting their neck. People often ask us about the difference between head shaking caused by essential tremor and that caused by dystonia. In this article Dr Marie-Helene Marion explains what the differences are and how neurologists tell if it is dystonia or not. The article is taken from her blog which can be found at

Millions of people all over the world use their head and neck to carry heavy goods. To do this, the control of the head posture needs to be phenomenal and does not allow any slight involuntary movement of the head. Unfortunately, for some people the head starts shaking even when they are not using their head as a way of carrying. This condition can be very disabling.

Head tremor is described a movement of oscillation of the head. It can make the head go side to side, which is called no-no tremor, or up and down, called yes-yes tremor. The tremor can be regular like a pendulum or irregular with the head movement becoming more pronounced from time to time.

Head tremor can be due to a condition called essential tremor (essential head tremor: EHT) or due to dystonia and in that case the tremor is labeled dystonic tremor (dystonic head tremor: DHT).

The clinical diagnosis of the different types of head tremor can be a dilemma when the head tremor appears in isolation from other symptoms, as neurologists don’t agree between themselves on the definition of dystonic tremor. Nevertheless, the distinction needs to be done, as the treatment and the prognosis may differ.


Table1: Differential diagnosis between essential head tremor and dystonic head tremor. Dr Marie-Helene Marion, 2013,


  1. Essential tremor (ET) is a clinical description of a familial regular tremor, which affects 50% of the siblings when one parent is affected.
  2. ET can affect hands, head, chin, tongue and voice.
  3. Women with ET have more chance of developing a head tremor.
  4. ET occurs when the body is in an upright posture, so the essential head tremor (EHT) is present when sitting or walking and disappears when lying down.
  5. ET, mainly when the tremor is affecting the hands, may be temporarily improved by drinking alcohol and may respond to beta-blockers drugs such as Propanolol.
  6. EHT is not controlled by sensory trick such as touching the cheek or the chin with the hand.
  7. EHT is always associated with other tremor in the arms or tongue or voice. A collaborative study between Turkey and USA looking at head tremor due to ET (583 ET cases) did not find any isolated cases of head tremor; all were associated with at least a mild hand tremor.


  1. Dystonic head tremor (DHT) causes an irregular head tremor, which is easy to diagnose when it occurs in a patient with an obvious cervical (neck) dystonia (with abnormal head posture and muscle spasms). In these cases, the condition is described as a tremulous cervical dystonia. DHT is one of the first symptoms of cervical dystonia in 30% of the cases and is reported in 30% to 60% of established cervical dystonia cases.
  2. DHT can also be present in absence of neck dystonia, but associated with other focal dystonias, such as blepharospasm, oromandibular dystonia, voice dystonia or even a writer’s cramp. Therefore patients with head tremor need to be examined thoroughly when speaking, eating, writing etc.


DHT can also be present without any associated dystonia on examination; the diagnosis in these cases is more difficult.

An additional problem for diagnosis is that there may be no family history of tremor or dystonia. Many dystonias do not have any known genetic cause and even when there is a genetic cause the dystonia symptoms may not appear in family members (to learn more about why this is click here). However, the diagnosis of dystonic head tremor will be made clinically on the basis of the following signs:

  1. The head tremor is irregular on observation
  2. The head tremor is relieved by a sensory tricks (similar to those which sometimes relieve cervical dystonia) such as placing the fingers on the cheek or the chin
  3. The head tremor persists when patient lying down.
  4. The head tremor is worst in certain position of the head (position dependant).
  5. The head tremor is associated with an irregular tremor of one hand, suggestive of a dystonic arm tremor (in contrast to an ET hand tremor which is regular and affects both hands)
  6. The head tremor is isolated, with no tremor in the hands or in the face or voice (in contrast to an EHT tremor which is always associated with tremor in other parts of the body).


Despite the fact that the patients are not always aware of their head tremor, in particular in case of EHT, it can be difficult to manage socially. However, head tremor can benefit from treatment such as oral medication and botulinum toxin injections. The appropriate treatment will depend on the type of tremor. Further research is needed to increase our understanding of this condition. Maybe new insights will come from an unexpected area of study – for instance head tremor also affects Doberman Pinsher dogs for reasons that are also not understood.

Dr Marie-Helene Marion is a London neurologist, specialist in dystonia and its treatment with botulinum toxin.



The Dystonia Society provides the information on this page as general information only. It is not intended to provide instruction and you should not rely on this information to determine diagnosis, prognosis or a course of treatment. It should not be used in place of a professional consultation with a doctor.

The Dystonia Society is not responsible for the consequences of your decisions resulting from the use of this information, including, but not limited to, your choosing to seek or not to seek professional medical care, or from choosing or not choosing specific treatment based on the information. You should not disregard the advice of your physician or other qualified health care provider because of any information you receive from us. If you have any health care questions, please consult the relevant medical practitioner.




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