Diagnostic Workup for Bilateral Upper Extremity Tremors and Daily Headaches

Initial Laboratory Evaluation

Thyroid function tests (TSH, free T4) should be ordered as both hypothyroidism and hyperthyroidism can cause tremors and headaches in patients with bilateral upper extremity tremors and daily headaches, according to the American Heart Association 1
Complete blood count (CBC) to evaluate for anemia or other hematologic abnormalities that could contribute to symptoms in patients with bilateral upper extremity tremors and daily headaches 1
Basic metabolic panel to assess for electrolyte disturbances, kidney function, and glucose levels in patients with bilateral upper extremity tremors and daily headaches 1
Liver function tests to rule out hepatic causes of tremor in patients with bilateral upper extremity tremors and daily headaches 1
Serum calcium to evaluate for hyperparathyroidism which can rarely present with tremor in patients with bilateral upper extremity tremors and daily headaches 1
Serum caffeine levels if high consumption is suspected in patients with bilateral upper extremity tremors and daily headaches, as recommended by the American Academy of Family Physicians 2

Urinary drug screen to rule out illicit substances that can cause tremor (cocaine, amphetamines) in patients with bilateral upper extremity tremors and daily headaches, according to the American Heart Association 1
Consider alcohol withdrawal as a potential cause of both tremor and headache in patients with bilateral upper extremity tremors and daily headaches, as recommended by the American Heart Association 1

Brain MRI with and without contrast is the preferred neuroimaging study to evaluate for structural causes of both tremor and headaches in patients with bilateral upper extremity tremors and daily headaches, as recommended by the American Society of Clinical Oncology 3
MRI can detect lesions that may cause both symptoms, including tumors, vascular malformations, or inflammatory processes in patients with bilateral upper extremity tremors and daily headaches, according to the American Academy of Neurology 5
Neuroimaging is particularly indicated with the presence of red flags such as new-onset headache in a patient over 50 years of age, progressively worsening headache pattern, headaches that wake the patient from sleep, headaches worsened by Valsalva maneuver, or abnormal neurological examination findings in patients with bilateral upper extremity tremors and daily headaches, as recommended by the American College of Physicians 4

Headache diary to document frequency, duration, intensity, and associated symptoms of headaches in patients with bilateral upper extremity tremors and daily headaches, as recommended by the International Headache Society 6
If chronic migraine is suspected (≥15 headache days per month for >3 months, with ≥8 days having migraine features), document response to migraine-specific medications in patients with bilateral upper extremity tremors and daily headaches, according to the American Headache Society 7
Consider lumbar puncture if there are concerns for increased intracranial pressure, especially if papilledema is present on fundoscopic examination in patients with bilateral upper extremity tremors and daily headaches, as recommended by the American Society of Clinical Oncology 3

Evaluate for cervical dystonia which can present with both tremor and headache in patients with bilateral upper extremity tremors and daily headaches, as recommended by the American Academy of Ophthalmology 8
Screen for sleep disorders, particularly if headaches occur upon awakening in patients with bilateral upper extremity tremors and daily headaches, according to the American Society of Clinical Oncology 3
Consider autoimmune panels if inflammatory or autoimmune processes are suspected in patients with bilateral upper extremity tremors and daily headaches, as recommended by the American Society of Clinical Oncology 3
In patients on immune checkpoint inhibitors, evaluate for immune-related adverse events that can present with both neurological symptoms in patients with bilateral upper extremity tremors and daily headaches, according to the American Society of Clinical Oncology 3

Abnormal thyroid function tests may indicate hyper/hypothyroidism as the cause of both tremor and headache in patients with bilateral upper extremity tremors and daily headaches, according to the American Heart Association 1
Structural abnormalities on MRI may require neurosurgical consultation in patients with bilateral upper extremity tremors and daily headaches, as recommended by the American Academy of Neurology 5
Consider the possibility of medication overuse headache if the patient is taking analgesics frequently in patients with bilateral upper extremity tremors and daily headaches, as recommended by the International Headache Society 6