Cervical dystonia tremor: clinical clues to diagnosis

Your patient has a head tremor. Is it cervical dystonia or essential tremor? An isolated head tremor is more likely to be caused by cervical dystonia than essential tremor. Look for abnormal neck posture and dystonic movements elsewhere in the body during your examination. This lesson uses patient videos to show the examination findings that support a diagnosis of cervical dystonia and help you distinguish it from essential tremor.

In this lesson from our Tremors Masterclass course, you’ll learn how to:

• Recognize cervical dystonia symptoms and abnormal neck postures
• Identify overflow dystonia in the face and body
• Assess how head position affects dystonic tremor
• Recognize a sensory trick and its diagnostic significance
• Consider neck pain when distinguishing cervical dystonia from essential tremor
• Distinguish cervical dystonia from essential head tremor using four key differences

Cervical dystonia symptoms

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Cervical dystonia is the most common type of adult-onset focal dystonia. Symptom onset tends to be between 40 to 60 years old, and it's about twice as common in females than in males. Patients typically present with a jerky and irregular tremor, abnormal neck posturing and/or pain. The abnormal neck posture occurs due to involuntary contractions of the neck muscles, which cause the head to tilt or rotate. Head rotation, known as torticollis, is the most common type of abnormal neck posture. The onset of the abnormal posture is gradual, so it may take several years before a diagnosis is made.

Cervical dystonia diagnosis: overflow dystonia and head position

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There are three clinical clues on exam that can help confirm the diagnosis. Number one. In addition to paying special attention to dystonic posturing of the neck, it's important to look for overflow dystonia into other body regions, especially in the face. Facial dystonia may be subtle, such as lip twitching, as shown here. Other signs of overflow dystonia to look out for include mild tongue protrusion, frequent eye blinking, or abnormal positioning of the eyebrows.

The second clue is that the tremor is often worse when the patient tries to hold it straight and improves when the patient allows the head to adopt the abnormal posture.

Sensory tricks in cervical dystonia

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And the third clue is the presence of a sensory trick. Time for another check-in question to test your knowledge. Think back to an earlier chapter. What is a sensory trick? Pause and think about the answer before moving on. Remember that a sensory trick is where the patient touches the affected body part, and by doing so, the dystonia or dystonia tremor improves or disappears completely. For example, this patient's abnormal head posturing improves when she touches her chin. This finding helps differentiate dystonia from other conditions. Another example is leaning their head back against a headrest. The sensory trick varies from patient to patient, so a sensory trick in one patient may not be helpful for another patient.

Neck pain in cervical dystonia

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In addition to these clinical clues, neck pain is a common symptom in patients with cervical dystonia. The pain is often local, but it may radiate from the neck down the arms. The diagnosis of cervical dystonia may be delayed in part because the pain symptoms are attributed to degenerative disease in the neck.

Cervical dystonia vs essential tremor

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When a patient presents with a head tremor, the two main diagnoses are cervical dystonia and essential tremor. Distinguishing between these can be challenging, but there are four key differences that can help you. Number one, an isolated head tremor is more likely to be caused by cervical dystonia than essential tremor. Number two, a sensory trick is specific for dystonia. Patients with essential tremor involving the head don't have a sensory trick. Three, while neck pain is common in cervical dystonia, patients with essential tremor don't have neck pain. And finally, overflow dystonia occurs when dystonic movements flow into other parts of the body. This doesn't occur with essential tremor.