Involuntary movements including hand tremor are uncommon but well recognized clinical manifestations after stroke. However, head tremor following acute stroke has rarely been described in the literature. I describe 4 patients who developed head tremor after acute stroke. They presented with side-to-side or up-and-down 2- to 4-Hz head tremor that was aggravated on sitting or standing and disappeared on sleeping. Imaging studies demonstrated infarcts (patients 1–3) and a hemorrhage (patient 4) each involving the paramedian pontomesencephalic region that may contain the crossing superior cerebellar peduncle. These cases illustrate that head tremor is a rare but distinct manifestation of stroke that primarily involves the paramedian pontomesencephalic are