Head tremor — involuntary ‘yes-yes’ or ‘no-no’ shaking of the head — responds poorly to medication and is one of the most socially disabling tremor presentations. Deep brain stimulation targeting the VIM, the posterior subthalamic area or the globus pallidus can substantially reduce it. In the case series of Prof. Atilla YILMAZ, MD, average head-tremor improvement has been 87%, with more than 70% of patients reaching near-complete resolution; individual results vary.
At a glance
- What it looks like
- Rhythmic horizontal (‘no-no’) or vertical (‘yes-yes’) head movement, worse when upright and under stress
- Common underlying causes
- Essential tremor with head involvement; cervical dystonia with dystonic tremor
- Why medication often fails
- Axial tremor responds less well to the drugs that help hand tremor; botulinum toxin helps some patients temporarily
- DBS targets used
- VIM; posterior subthalamic area (PSA/cZi); globus pallidus internus (GPi) when dystonia predominates
- Average improvement
- 87% (our case series — results vary)
- Near-complete resolution
- More than 70% of patients in our case series — results vary
Why head tremor is treated differently
Hand tremor and head tremor are not simply the same problem in different places. Head tremor is an axial, midline symptom, driven by muscles on both sides of the neck, and it usually requires stimulation on both sides to control. It also sits at the boundary between two diagnoses: isolated head tremor may be part of essential tremor, or it may be the tremor component of cervical dystonia. The distinction changes the target.
The first task in assessment is therefore diagnostic. Is there a directional preference or a null point — a head position in which the tremor quiets? Is there a sensory trick (geste antagoniste) — touching the chin or cheek reduces it? Is there sustained turning or tilting, not just shaking? Those features point to dystonia, and towards pallidal stimulation.
Target selection
| Presentation | Usual target | Reasoning |
|---|---|---|
| Head tremor within essential tremor, no dystonic features | VIM and/or PSA, bilateral | Classical tremor circuit; PSA often effective at lower amplitude |
| Dystonic head tremor with cervical dystonia | GPi, bilateral | Addresses the dystonic posture as well as the tremor |
| Mixed or unclear, or incomplete response to one target | Double targeting of VIM and PSA on one trajectory | Allows stimulation to be balanced between targets during programming |
A technique developed for exactly this problem
Head tremor is the presentation that most often defeats a single target. It is axial, it sits between essential tremor and cervical dystonia, and patients frequently arrive after medication, botulinum toxin and sometimes previous surgery have all given only partial relief. This is the group for which Prof. YILMAZ and colleagues described double targeting of the VIM and the posterior subthalamic area through a single electrode trajectory, published in Stereotactic and Functional Neurosurgery in 2024 with Prof. Patric Blomstedt of Umeå University.
Because both targets sit on one lead, stimulation can be balanced between them during programming and rebalanced months later — without a second pass through the brain. In this practice's series, head tremor has been the indication where that flexibility has paid off most: average improvement has been 87%, with more than 70% of patients reaching near-complete resolution. These are averages from one centre's case series and individual results vary.
Peer-reviewed publicationDeep Brain Stimulation with Double Targeting of the VIM and PSA for the Treatment of Rare Tremor SyndromesYilmaz A, Eray HA, Çakır M, Ceylan M, Blomstedt P. Stereotactic and Functional Neurosurgery, 2024 · doi:10.1159/000539162 · PubMed 38934181What improvement actually looks like
Patients describe the change less in clinical terms than in social ones: being able to look someone in the eye during a conversation, to be photographed, to eat in a restaurant, to be seen on a video call without explaining. Head tremor is visible in a way hand tremor is not, and much of its burden is social withdrawal.
Timing differs by mechanism. Where the tremor is essential-type, improvement is usually apparent quickly once stimulation is optimised. Where dystonia predominates and the pallidum is stimulated, benefit typically develops gradually over weeks to months — patients need to be told this in advance, because early disappointment is otherwise common.
Assessment by video
Head tremor is well suited to remote assessment, because it is visible. For a candidacy review Prof. YILMAZ asks for short videos: the head at rest while sitting relaxed; while looking straight ahead; while turning to each side; while writing or drinking; and, importantly, an attempt at a sensory trick. Together with the neurologist's report, this is usually enough to give a preliminary opinion.
See it for yourself
Head tremor is visible, which means results are visible too. The centre publishes a video series of head tremor patients before and after deep brain stimulation, recorded with their written consent.
Video series · 40 videosHead Tremor Treatment with Deep Brain Stimulation (DBS)Before-and-after recordings of head tremor patients, on the Neuromodulation in Turkey channel. Individual results vary.Send head tremor videos for review
Outcome figures are averages for the head tremor patients within this practice's consecutive series of more than 800 deep brain stimulation procedures performed by Prof. Atilla YILMAZ, MD and his team. Individual results vary and no outcome is guaranteed.
Frequently asked questions
Can head tremor be treated with DBS?
Yes. Bilateral stimulation of the VIM, the posterior subthalamic area, or the globus pallidus internus — depending on whether the tremor is essential-type or dystonic — substantially reduces head tremor in most appropriately selected patients.
How effective is DBS for head tremor?
In the case series of Prof. Atilla YILMAZ, MD, average improvement in head tremor has been 87%, with more than 70% of patients achieving near-complete resolution. These are averages from one centre's series; individual results vary.
Is botulinum toxin better than DBS for head tremor?
They are different tools. Botulinum toxin injections can help, particularly when there is a dystonic component, but the effect wears off after a few months and needs repeating, and it helps posture more reliably than tremor. DBS is considered when injections give insufficient or short-lived benefit.
Does head tremor need stimulation on both sides?
Almost always. The head is a midline structure moved by muscles on both sides, so unilateral stimulation usually gives only partial control.