HIFU for Essential Tremor: The Noninvasive Treatment that Offers Instant Relief

The woman’s hands shook so badly she could barely hold a pen to write her name. She avoided eating in public, knowing that lifting a spoonful of soup might cause it to splatter. She’d had a neurological condition called essential tremor for decades, and it made her shake uncontrollably, an exhausting experience.

But everything changed after she had a noninvasive treatment called high-intensity focused ultrasound (HIFU). This groundbreaking procedure is changing daily life for people who have tremors, which affect an estimated 5% to 10% of the population, according to Yale Medicine neurosurgeon Zion Zibly, MD, MBA.

HIFU is a noninvasive treatment that provides immediate relief for people who experience tremors, whether they are caused by essential tremor, tremor-dominant Parkinson’s disease, or a similar condition. HIFU uses focused ultrasonic waves to create a small lesion in a spot deep in the brain that is associated with the tremor, quickly disarming it. It’s a solution for people for whom medication has failed and who want to avoid brain surgery, which might have been their next step.

“It’s a life-changing procedure,” says Dr. Zibly, who is the director of Yale Medicine’s Focused Ultrasound program. After he treated the woman whose tremors affected her hands for decades, Dr. Zibly says she wept when she realized her tremor was gone. A leading researcher in the field, Dr. Zibly helped pioneer HIFU, a breakthrough treatment he says can reduce tremors by as much as 92%. “Once the treatment is complete, you go home the same day without the disability,” he says.

With nearly 300 HIFU procedures performed over the past decade, Dr. Zibly is one of the most experienced specialists in this innovative treatment. He was instrumental in its earliest research and development, and began offering it to patients at Yale New Haven Health’s Long Ridge Medical Center in Stamford, an outpatient facility, in early 2025.

The Food and Drug Administration (FDA) approved HIFU to treat essential tremor in 2016, but only for one side of the brain, which meant relief on only one side of the body. In 2023, the FDA expanded its approval to allow the procedure on the second side of patients’ brains, nine months after the first treatment. While the approach is not available everywhere in the United States, more doctors are learning to use it, Dr. Zibly says.

Dr. Zibly, who treated his first patient at Greenwich Hospital early this year, spoke to us about HIFU and how it works, why he considers it to be groundbreaking, and who it can help.

Essential tremor is the most common type of tremor, marked by involuntary, rhythmic shaking—usually in the hands, but sometimes affecting the head, face, voice, and legs. While it can be confused with other types of tremor, including Parkinson’s-related tremor, essential tremor differs in a number of ways.

“Essential tremor tends to be most noticeable during movement—like when you’re holding a cup of coffee or writing,” explains Dr. Zibly, a neurologist specializing in movement disorders. “In contrast, tremors linked to Parkinson’s disease typically show up when the body is at rest.”

Tremors, including both essential and Parkinson’s-related types, are said to affect 5 to 10% of the population, says Dr. Zibly. “And that range is probably low,” he adds. “The condition is often undiagnosed, so many people are never referred to a specialist who can identify it and treat it,” he says.

While a person can develop essential tremor at any age, it most commonly begins in people in their 30s and 40s. Parkinson’s-related tremor typically starts later, when a person reaches their 50s or 60s, Dr. Zibly adds. Tremors may be intermittent or constant, and while some are only mildly bothersome, others can interfere with daily life—making it difficult to work, write, or even eat without assistance. The condition can lead to problems such as social anxiety, difficulty holding a job, and isolation due to embarrassment or frustration.

About half of all essential tremor cases appear to have a strong genetic link, Dr. Zibly says. If a close family member has tremors, a person’s risk may be higher. Still, many cases develop without a clear cause.

Many tremors are mild enough to manage with lifestyle changes, such as eliminating caffeine or getting better sleep. Most people don’t need additional treatment. For those who do, there are medications, although they don’t work for everyone and may lose effectiveness over time.

For people with severe or disabling tremors that don’t respond to medication, a surgical treatment called deep brain stimulation (DBS) may be an option. DBS involves implanting a small, pacemaker-like device in the brain that delivers electrical pulses to the precise spot in the brain that regulates movement. “But it's an invasive procedure,” Dr. Zibly says. ”Not all patients want to have brain surgery and some may have medical conditions or take medications that make it too risky.”

HIFU uses MRI guidance to deliver focused ultrasound waves—through the scalp and into the brain—to the single spot of tissue that causes the troublesome tremors.

Before the procedure, patients are evaluated using an MRI to map the brain to help pinpoint the spot in the basal ganglia, a part of the brain that is primarily involved in motor control. “The spot we target is hyperactive,” Dr. Zibly says. “In order to deactivate it, we need to safely destroy it.”

On the day of the procedure, the first step is to shave the patient’s entire head, since hair can interfere with the flow of the ultrasonic waves. Next, the patient lays comfortably in an MRI machine, which acts as a real-time GPS, allowing the medical team to precisely target the basal ganglia.

During the procedure, a special helmet is worn to send thousands of ultrasound beams through the scalp and skull to the focused point. These beams pass harmlessly through the scalp and skull, converging precisely at the tiny target area deep within the brain. A cooling cap within the helmet protects the scalp from heat. It’s a painless procedure, so anesthesia is not needed.

Once the beams reach the intended spot, the team carefully directs them to make a tiny, controlled “dry lesion”—a very precise, microscopic burn. Because the patient is awake, the team asks them to perform simple tasks, like drawing or writing, and report any sensations. “This allows the team to immediately see positive effects, such as a decrease in the tremors, or to adjust if there are any unwanted effects, such as a temporary weakness of the hand,” Dr. Zibly says. This real-time feedback ensures incredible precision.

Once the target is confirmed, the ultrasonic wave energy is gradually increased. This heat permanently deactivates that specific, hyperactive area of the brain. In most cases, the tremors begin to decrease in a matter of seconds.

The treatment takes about an hour and 15 minutes, Dr. Zibly says.

While HIFU is not a 100% cure, patients notice a “remarkable” improvement in daily tasks such as drawing spirals and writing their names, which they are asked to do before and after the procedure. Dr. Zibly recalls one patient was thrilled to be able to drink a glass of water without uncontrollable shaking.

One of HIFU’s standout advantages is its simplicity after treatment—there is no long-term follow-up or maintenance. The most common side effect is a temporary unsteadiness in gait, affecting between 1% and 2% of patients. It typically resolves within a couple of weeks. “The quality of life should be almost back to normal,” Dr. Zibly says,

HIFU has demonstrated impressive long-term effectiveness, reducing tremors for at least five years. While tremors may return in about 5% of patients, those individuals may choose to have the procedure again, says Dr. Zibly.

Anyone considering HIFU treatment should consult a team of specialists, which should include both a functional neurosurgeon—one who uses various techniques to improve the function of the nervous system—and a neurologist who specializes in movement disorders, Dr. Zibly says.

In addition to being helpful for individuals who experience severe tremors, Dr. Zibly encourages some people with mild tremors to consider the treatment. One patient, a woman in her 90s, told him she lived alone, and needed better motor control in order to cook for herself and clean her house. “If, for example, someone is a pilot, or a painter, even a mild tremor could interfere with their work,” Dr. Zibly says. “So I think the question is, ‘How much does the patient’s tremor impact their life?’”

Dr. Zibly’s interest in HIFU extends beyond using it to treat tremors. This technology is also being used to treat other conditions such as enlarged prostate and uterine fibroids. Looking ahead, researchers are actively studying its potential use for neurological conditions as epilepsy, addiction, and even obesity.

“The longer we study HIFU and the longer we study the brain, the better we'll be able to treat more and more symptoms,” Dr. Zibly says, hinting at a transformative future for noninvasive medicine.