Involuntary Head Movement: Why Your Head Shakes, Bobs or Nods, and How It Is Treated

An involuntary head movement is any movement of the head that happens without you meaning it to. The head may shake from side to side as if saying “no”, bob up and down as if saying “yes”, jerk, nod, or turn and tilt to one side. Some people notice it only when they are tired or stressed. Others find it is there most of the day and gets in the way of reading, eating, driving or talking to people.

Most involuntary head movements are not dangerous, and many can be treated. The two most common causes in adults are essential tremor and cervical dystonia, a condition in which the neck muscles contract on their own. Medicines, caffeine, anxiety, thyroid problems, tic disorders and conditions of the brain can also cause them. In babies, head bobbing and nodding have their own set of causes. This guide explains what the different movements look like, what usually causes them, when to see a doctor and which treatments help.

Doctors describe abnormal movements by their pattern, because the pattern points to the cause. The main types that affect the head are:

• Tremor: a rhythmic, to-and-fro movement. A head tremor can be a “no-no” (side to side) movement, a “yes-yes” (up and down) movement, or a mix of both. [1]
• Dystonia: the neck muscles tighten on their own and pull the head into a turn or a tilt, or forward or backward. It is often uncomfortable and can come with a jerky, irregular tremor. [5]
• Tics: sudden, brief movements such as a head jerk, nod or shake that repeat. Many people feel an urge before a tic and can hold it back for a short time.
• Chorea: irregular, flowing movements that seem to move from one part of the body to another.
• Myoclonus: sudden, shock-like jerks of the head or neck.
• Titubation: a slower bobbing of the head, and sometimes the upper body, usually caused by a problem in the cerebellum, the part of the brain that coordinates movement.

If the movement comes and goes, a short phone video is one of the most useful things you can show your doctor.

Head bobbing is a rhythmic up-and-down or forward-and-back movement of the head. In adults, the most common cause is a “yes-yes” head tremor. In a study of people with essential tremor who had a head tremor, 17.6% had a “yes-yes” tremor, 27.5% had a “no-no” tremor and 54.9% had a mix of both. [3] The same study suggests that head tremor starts as an occasional movement in one direction and, over the years, becomes more frequent and mixed. [3]

• Essential tremor: a “yes-yes” head tremor looks like gentle, repeated nodding or bobbing. It shows when the head is held upright and usually settles when you lie down with your head supported.
• Cervical dystonia: a dystonic head tremor can look like bobbing, but it is usually jerkier and comes with the head pulling to one side. [5]
• Problems in the cerebellum: multiple sclerosis, a stroke at the back of the brain, long-term heavy drinking and some inherited conditions can damage the cerebellum and cause titubation, often with unsteady walking and clumsy hands.
• A heart valve problem: rarely, a head that bobs in time with the heartbeat is a sign of a badly leaking aortic valve (aortic regurgitation). Doctors call this de Musset’s sign. It comes with other signs, such as a strong, bounding pulse, and needs a heart check.
• Sleepiness: the head drops and jerks back up when you nod off while sitting. This is normal, but if it happens often during the day, ask your doctor about sleep problems such as sleep apnea.

Young babies’ heads wobble because their neck muscles are still getting stronger, and most babies hold their heads steady by about four months. Some other causes need a doctor’s review:

• Spasmus nutans: a combination of head nodding or bobbing, small shaking movements of the eyes (nystagmus) and a head tilt. It usually starts in the first year or two of life and often fades over a few years. The same signs can be caused by eye, brain or other conditions, so children with them need an eye examination and often a brain scan. [10]
• Infantile spasms: clusters of sudden, brief head drops or bending of the body, often just after waking. They are a type of seizure and need urgent medical attention.
• Rhythmic movements at bedtime: many toddlers rock, roll their heads or bang their heads as they fall asleep. This is common, usually harmless and fades with age.
• Tics: tics usually begin in childhood, and head jerks, nods and shakes are common ones.

Head shaking that you cannot control has several possible causes. These are the most common.

Essential tremor is the most common adult movement disorder. About 0.9% of people of all ages have it, rising to about 4.6% of people aged 65 and over. [2] It mainly causes shaking of both hands and arms when you use them, for example when writing, drinking from a cup or holding a phone, and some people also have a tremor of the head or voice. [1] A head tremor with no hand tremor at all is classed separately, and doctors check whether it is a sign of cervical dystonia. [1, 5]

Essential tremor often runs in families. It tends to get worse with stress, tiredness and caffeine, and many people notice that a small amount of alcohol eases it for a while.

Cervical dystonia, also called spasmodic torticollis, makes the neck muscles contract on their own. The head may turn to one side, tilt toward a shoulder, or be pulled forward or backward. [5] The neck and shoulders often ache, and many people also have an irregular, jerky head tremor. [5]

Typical clues are that the shaking is irregular, it gets worse when you try to hold your head straight against the pull, and it eases when you let your head go the way it is being pulled. Many people also find that lightly touching the chin, cheek or back of the head calms the movement, which doctors call a “sensory trick”. Cervical dystonia usually starts between the ages of 30 and 70. [5] It is more common in women than in men.

Everyone has a very fine tremor that is normally too small to see. When something makes it bigger, doctors call it enhanced physiological tremor. Common causes are anxiety, tiredness, an overactive thyroid and some medicines, and the tremor usually settles once the cause is dealt with. [1] Low blood sugar and alcohol withdrawal can have the same effect.

Caffeine and asthma medicines such as salbutamol are well-known causes of tremor. [7] Other medicines that can cause or worsen tremor include valproate, lithium, some antidepressants, amiodarone and too high a dose of thyroid hormone. [7]

Many people worry that a shaking head means Parkinson’s disease. In fact, head tremor is uncommon in Parkinson’s. Its tremor usually starts in one hand while the hand is resting, and it can affect the jaw, lips or chin. Other early signs include slowness, stiffness, smaller handwriting and a softer voice.

Anxiety and stress make any tremor more noticeable. Sometimes a tremor comes from a problem with how the brain sends and receives movement signals rather than from damage to the brain. This is called a functional tremor. It is a real, involuntary condition. It often changes when the person is distracted and can improve with specialist physiotherapy and psychological therapy.

Conditions that affect the cerebellum or its connections, such as multiple sclerosis, a stroke, a brain injury or, rarely, a tumor, can cause head bobbing or tremor. These usually come with other symptoms such as unsteadiness, slurred speech, double vision, numbness or weakness. Head movements that start suddenly with any of these symptoms need emergency care.

• Medicine side effects: medicines that block dopamine, such as some antipsychotics and the anti-sickness medicine metoclopramide, can cause sudden neck spasms (acute dystonia) within days of starting them. Taken for a long time, they can also cause tardive syndromes such as tardive dyskinesia, which brings repeated movements of the mouth and face and sometimes of the neck and body. [8]
• Tic disorders and Tourette syndrome: head jerks, nods and shakes are common tics, along with blinking, shoulder shrugging and throat clearing.
• Huntington’s disease: an inherited condition that causes chorea, along with changes in mood and thinking.
• Wilson’s disease: a rare inherited condition in which copper builds up in the body. It can cause tremor or dystonia in teenagers and younger adults.
• Infections and inflammation of the brain: rare causes, which usually come with fever, confusion or headache.

• Older adults: essential tremor becomes more common with age. [2]
• Adults aged 30 to 70: cervical dystonia usually starts at these ages. [5]
• Children: tics and spasmus nutans start in childhood.
• People with a family history: essential tremor, some types of dystonia and Huntington’s disease can run in families.
• People taking dopamine-blocking medicines: especially when they take them for a long time.

See a doctor if a head movement is new, getting worse or affecting your daily life. Get help sooner in these situations:

• Call emergency services if head movements start suddenly together with weakness or numbness on one side, a drooping face, slurred speech, loss of vision, a severe headache or confusion. These can be signs of a stroke.
• Get urgent care if your neck twists or your eyes roll up after starting a new medicine, or if a baby has clusters of sudden head drops.
• Book an appointment soon if a baby or young child nods or bobs their head with shaky eyes or a head tilt, if your head is being pulled to one side, or if the movements began after a new medicine.

Most causes can be identified from your history and an examination. Your doctor will usually ask:

• When the movement started and whether it is constant or comes and goes
• Whether it is a “no-no”, “yes-yes” or pulling movement, and whether it stops when you lie down
• What makes it better or worse, such as stress, caffeine, alcohol or touching your face
• Which medicines you take, including any recent changes
• Whether anyone in your family has a tremor or another movement disorder

During the examination, the doctor watches your head at rest and while you hold it upright, checks your hands (for example by asking you to hold out your arms or draw a spiral), and looks at your eye movements, walking, balance and reflexes.

Tests depend on what the doctor finds. They may include blood tests for thyroid function, blood sugar, salts, and liver and kidney function, and copper tests in younger people. A brain MRI scan is used when there are other neurological signs, when the movement started suddenly, and in children with signs of spasmus nutans. [10] When it is unclear whether a tremor is essential tremor or Parkinson’s disease, a DaT scan can help tell them apart. Some specialist clinics also measure the movement with sensors.

There is no single treatment for uncontrollable head movements, because the right treatment depends on the cause. The aim is to reduce the movement and any pain, and to make daily life easier.

If a medicine, caffeine, an overactive thyroid or alcohol withdrawal is behind the movement, dealing with that cause is often enough. [7] Never stop a prescribed medicine on your own, because your doctor can usually lower the dose or switch you to another one.

Treatment is only needed if the tremor bothers you. Propranolol and primidone are the medicines with the strongest evidence, and topiramate at higher doses is another option. [4] Propranolol is not suitable for people with asthma, and primidone can cause drowsiness and unsteadiness at first, so it is started at a low dose.

The evidence for treating head tremor in particular is limited. [4] Some specialists use botulinum toxin injections into the neck muscles for a troublesome head tremor. For severe tremor that medicines do not control, deep brain stimulation or focused ultrasound treatment of a small area of the thalamus may be considered. [4]

Botulinum toxin injections into the overactive neck muscles are the main treatment. A Cochrane review found that a single treatment session reduces the problems cervical dystonia causes and its pain, and that the injections are well tolerated, although some people get difficulty swallowing, neck weakness or tiredness. [6] The effect wears off after a few months, so the injections are usually repeated about every three months.

Tablets such as trihexyphenidyl, clonazepam or baclofen help some people. Physiotherapy can improve posture and pain, and deep brain stimulation is an option when other treatments have not worked.

The doctor first reviews the medicine that caused the problem. For tardive dyskinesia, deutetrabenazine and valbenazine are established as effective treatments. [8] A sudden neck spasm after a new medicine usually settles quickly with treatment.

Many tics are mild and need no treatment. Options include watchful waiting, a behavioral therapy called Comprehensive Behavioral Intervention for Tics, and medicines. [9] For adults with severe tics that do not respond to other treatments, deep brain stimulation can be considered. [9]

• Cut down on coffee, tea, energy drinks and other sources of caffeine.
• Do not use alcohol to calm a tremor. The effect is short-lived and can lead to heavier drinking.
• Sleep well and manage stress with exercise, relaxation or breathing techniques.
• Rest your head against a high-backed chair when reading or watching television, and use a headset for phone calls.
• Keep a diary or short videos of when the movement is worse, to show your doctor.

It depends on the cause. Tremor caused by caffeine, anxiety, an overactive thyroid or a medicine usually settles once the cause is dealt with. Spasmus nutans often fades in early childhood, and tics often ease during the teenage years. Essential tremor and cervical dystonia are usually long-term conditions, but treatment controls the symptoms well for many people.

Usually not. Head tremor is uncommon in Parkinson’s disease, and a shaking head is more often caused by essential tremor or cervical dystonia. A tremor that starts in one hand at rest, together with slowness and stiffness, is more typical of Parkinson’s.

Yes. Anxiety can make the normal fine tremor visible and make an existing tremor or tic worse. If the movements continue when you are calm, see a doctor to look for another cause.

When you nod off while sitting, your neck muscles relax and your head drops, then jerks back up as you wake. Tiredness can also make a tremor more noticeable. Nodding off often during the day is worth discussing with a doctor.

Some head wobbling is normal in the first months while the neck muscles strengthen. See a doctor if your baby nods or bobs with shaking eyes or a head tilt, or has sudden head drops in clusters.

A small amount of alcohol eases essential tremor for a while in many people, and doctors may ask about it because it helps with the diagnosis. It is not a treatment, because the tremor can come back worse and regular drinking carries its own risks.

When there is a clear trigger, such as a medicine or an overactive thyroid, treating it can stop the movement. Essential tremor and cervical dystonia cannot usually be cured, but medicines, injections and, in severe cases, surgery can control them.

An involuntary head movement can be worrying, but it is rarely a sign of something dangerous. The pattern of the movement, what makes it better or worse and the medicines you take usually point to the cause. Essential tremor and cervical dystonia are the most common causes in adults, and both can be treated. See a doctor if the movement is new, getting worse or affecting your life, and get emergency help if it comes on suddenly with weakness, numbness, speech problems or a severe headache.

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