Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

symptoms not interfering with activities of daily living

1st line – psychoeducation and support

Back
ACUTE
|
symptoms not interfering with activities of daily living
1st line – 

psychoeducation and support

Most tics in children are mild and do not require treatment.

Psychoeducation for the patient and their parents, teachers, and peers is the most important initial step.[53] Patients and their parents should be reassured that the prognosis is favourable for the majority of people affected by tics. They should also be made aware of the tendency for tics to increase in times of stress, anxiety, transitions, and excitement. The family and the school should be advised to try not to focus on the presence of the tics.

Patients should be assessed for comorbid disorders, such as ADHD, obsessive-compulsive disorder (OCD), anxiety, and mood and disruptive behaviour disorders.[53]

symptoms interfering with activities of daily living: non-pregnant

1st line – behavioural therapy + psychoeducation and support

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics not severe
1st line – 

behavioural therapy + psychoeducation and support

Psychoeducation for the patient and their parents, teachers, and peers is the most important initial step.[53] Patients and their parents should be reassured that the prognosis is favourable for the majority of people affected by tics. They should also be made aware of the tendency for tics to increase in times of stress, anxiety, transitions, and excitement. The family and the school should be advised to try not to focus on the presence of the tics.

Patients should be assessed for comorbid disorders, such as ADHD, obsessive-compulsive disorder (OCD), anxiety, and mood and disruptive behaviour disorders.[53]

Behavioural therapies are an essential component in the treatment of tics. Comprehensive behavioural intervention for tics (CBIT) is a programme that includes habit reversal training, relaxation training, and a functional intervention to address situations that sustain or worsen tics. CBIT (if available) is recommended as an initial treatment option relative to other psychosocial/behavioural interventions and relative to medication.[53] Most children and adults showing an initial positive response to CBIT maintain treatment gains for at least 6 months. Effectiveness of CBIT appears similar to that of medication, and there is some evidence that effectiveness is greater for patients not taking anti-tic medication at the same time.[53][54][55][56] Most studies have been conducted with participants aged 9 years and older, but an open trial in children 5 to 8 years demonstrated beneficial effects of CBIT in this age group.[57]

Other behavioural therapies that may be used to treat tics if CBIT is not available include exposure and response prevention (ERP), habit reversal training (as a stand-alone therapy), and cognitive behavioural therapy.[53][58][59][60][61]

Behavioural therapies are delivered by trained professionals, including psychologists, occupational therapists, and speech therapists.[62][63][64] However, this type of therapy may not be easily accessible in some communities. If face-to-face options are unavailable, therapies may be delivered via videoconference or teleconference, or using online learning modules, although evidence for effectiveness is limited.[53][61]

Consider – alpha-2-adrenergic agonist

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics not severe
Consider – 

alpha-2-adrenergic agonist

Additional treatment recommended for SOME patients in selected patient group

When medication is considered appropriate (i.e., after, or in addition to, behavioural therapy), alpha-2-adrenergic agonists are preferred as first-line pharmacological agents.[56] Although a lower efficacy is reported when used in tic disorders without comorbid conditions, clinicians and their patients may be more willing to try an alpha-2-adrenergic agonist for tics before moving to 'stronger' medications.[13][53][65][66] Options include oral or transdermal clonidine and oral guanfacine.[13][53][67]

Alpha-2-adrenergic agonists are associated with fewer and less serious adverse effects than antipsychotic (neuroleptic) medications, but caution should be used due to the potential risk of daytime fatigue. Heart rate and blood pressure should be monitored in all patients, and QTc interval monitored in high-risk patients taking guanfacine.[53]  

The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

clonidine: consult specialist for guidance on dose

OR

clonidine transdermal: consult specialist for guidance on dose

OR

guanfacine: consult specialist for guidance on dose

Consider – botulinum toxin type A injection

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics not severe
Consider – 

botulinum toxin type A injection

Additional treatment recommended for SOME patients in selected patient group

Botulinum toxin type A injections can be used in adults and older adolescents with simple focal motor tics affecting the face or neck region, or with severely disabling or aggressive vocal tics.[53] This therapy is not suitable for patients who have complex tics involving multiple muscle groups. Injections are delivered directly into the affected muscles.

There is some evidence for a significant decrease in tics and premonitory urges with botulinum toxin type A injection compared with placebo in people with simple motor tics, but additional randomised controlled studies are needed.[68][69]

Referral to a movement disorders specialist is required. The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

botulinum toxin type A: consult specialist for guidance on dose

2nd line – alpha-2-adrenergic agonist

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics not severe
2nd line – 

alpha-2-adrenergic agonist

When medication is considered appropriate (i.e., after, or in addition to, behavioural therapy), alpha-2-adrenergic agonists are preferred as first-line pharmacological agents.[56] Although a lower efficacy is reported when used in tic disorders without comorbid conditions, clinicians and their patients may be more willing to try an alpha-2-adrenergic agonist for tics before moving to 'stronger' medications.[13][53][65][66] Options include oral or transdermal clonidine and oral guanfacine.[13][53][67]

Alpha-2-adrenergic agonists are associated with fewer and less serious adverse effects than antipsychotic (neuroleptic) medications, but caution should be used due to the potential risk of daytime fatigue. Heart rate and blood pressure should be monitored in all patients, and QTc interval monitored in high-risk patients taking guanfacine.[53]  

The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

clonidine: consult specialist for guidance on dose

OR

clonidine transdermal: consult specialist for guidance on dose

OR

guanfacine: consult specialist for guidance on dose

Consider – behavioural therapy

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics not severe
Consider – 

behavioural therapy

Additional treatment recommended for SOME patients in selected patient group

Comprehensive behavioural intervention for tics (CBIT) is a programme that includes habit reversal training, relaxation training, and a functional intervention to address situations that sustain or worsen tics. CBIT (if available) is recommended as an initial treatment option relative to other psychosocial/behavioural interventions and relative to medication.[53] Most children and adults showing an initial positive response to CBIT maintain treatment gains for at least 6 months. Effectiveness of CBIT appears similar to that of medication, and there is some evidence that effectiveness is greater for patients not taking anti-tic medication at the same time.[53][54][55][56] Most studies have been conducted with participants aged 9 years and older, but an open trial in children 5 to 8 years demonstrated beneficial effects of CBIT in this age group.[57]

Other behavioural therapies that may be used to treat tics if CBIT is not available include exposure and response prevention (ERP), habit reversal training (as a stand-alone therapy), and cognitive behavioural therapy.[53][58][59][60][61]

Behavioural therapies are delivered by trained professionals, including psychologists, occupational therapists, and speech therapists.[62][63][64] However, this type of therapy may not be easily accessible in some communities. If face-to-face options are unavailable, therapies may be delivered via videoconference or teleconference, or using online learning modules, although evidence for effectiveness is limited.[53][61]

Consider – botulinum toxin type A injection

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics not severe
Consider – 

botulinum toxin type A injection

Additional treatment recommended for SOME patients in selected patient group

Botulinum toxin type A injections can be used in adults and older adolescents with simple focal motor tics affecting the face or neck region, or with severely disabling or aggressive vocal tics.[53] This therapy is not suitable for patients who have complex tics involving multiple muscle groups. Injections are delivered directly into the affected muscles.

There is some evidence for a significant decrease in tics and premonitory urges with botulinum toxin type A injection compared with placebo in people with simple motor tics, but additional randomised controlled studies are needed.[68][69]

Referral to a movement disorders specialist is required. The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

botulinum toxin type A: consult specialist for guidance on dose

3rd line – topiramate

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics not severe
3rd line – 

topiramate

Topiramate may be a useful alternative for treating tics in patients who have comorbid obesity (due to the potential for minimal effects on weight associated with this medication), sleep difficulty, or migraine headaches.[53][76][77]

The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder. Starting with a low dose at night and very slowly increasing the dose is recommended to limit adverse effects. Very low doses can be effective in some patients, while others may require higher doses.

Primary options

topiramate: consult specialist for guidance on dose

Consider – behavioural therapy

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics not severe
Consider – 

behavioural therapy

Additional treatment recommended for SOME patients in selected patient group

Comprehensive behavioural intervention for tics (CBIT) is a programme that includes habit reversal training, relaxation training, and a functional intervention to address situations that sustain or worsen tics. CBIT (if available) is recommended as an initial treatment option relative to other psychosocial/behavioural interventions and relative to medication.[53] Most children and adults showing an initial positive response to CBIT maintain treatment gains for at least 6 months. Effectiveness of CBIT appears similar to that of medication, and there is some evidence that effectiveness is greater for patients not taking anti-tic medication at the same time.[53][54][55][56] Most studies have been conducted with participants aged 9 years and older, but an open trial in children 5 to 8 years demonstrated beneficial effects of CBIT in this age group.[57]

Other behavioural therapies that may be used to treat tics if CBIT is not available include exposure and response prevention (ERP), habit reversal training (as a stand-alone therapy), and cognitive behavioural therapy.[53][58][59][60][61]

Behavioural therapies are delivered by trained professionals, including psychologists, occupational therapists, and speech therapists.[62][63][64] However, this type of therapy may not be easily accessible in some communities. If face-to-face options are unavailable, therapies may be delivered via videoconference or teleconference, or using online learning modules, although evidence for effectiveness is limited.[53][61]

Consider – botulinum toxin type A injection

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics not severe
Consider – 

botulinum toxin type A injection

Additional treatment recommended for SOME patients in selected patient group

Botulinum toxin type A injections can be used in adults and older adolescents with simple focal motor tics affecting the face or neck region, or with severely disabling or aggressive vocal tics.[53] This therapy is not suitable for patients who have complex tics involving multiple muscle groups. Injections are delivered directly into the affected muscles.

There is some evidence for a significant decrease in tics and premonitory urges with botulinum toxin type A injection compared with placebo in people with simple motor tics, but additional randomised controlled studies are needed.[68][69]

Referral to a movement disorders specialist is required. The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

botulinum toxin type A: consult specialist for guidance on dose

1st line – behavioural therapy + psychoeducation and support

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics severe
1st line – 

behavioural therapy + psychoeducation and support

Psychoeducation for the patient and their parents, teachers, and peers is the most important initial step.[53] Patients and their parents should be reassured that the prognosis is favourable for the majority of people affected by tics. They should also be made aware of the tendency for tics to increase in times of stress, anxiety, transitions, and excitement. The family and the school should be advised to try not to focus on the presence of the tics.

Patients should be assessed for comorbid disorders, such as ADHD, obsessive-compulsive disorder (OCD), anxiety, and mood and disruptive behaviour disorders.[53]

Behavioural therapies are an essential component in the treatment of tics. Comprehensive behavioural intervention for tics (CBIT) is a programme that includes habit reversal training, relaxation training, and a functional intervention to address situations that sustain or worsen tics. CBIT (if available) is recommended as an initial treatment option relative to other psychosocial/behavioural interventions and relative to medication.[53] Most children and adults showing an initial positive response to CBIT maintain treatment gains for at least 6 months. Effectiveness of CBIT appears similar to that of medication, and there is some evidence that effectiveness is greater for patients not taking anti-tic medication at the same time.[53][54][55][56] Most studies have been conducted with participants aged 9 years and older, but an open trial in children 5 to 8 years demonstrated beneficial effects of CBIT in this age group.[57]

Other behavioural therapies that may be used to treat tics if CBIT is not available include exposure and response prevention (ERP), habit reversal training (as a stand-alone therapy), and cognitive behavioural therapy.[53][58][59][60][61]

Behavioural therapies are delivered by trained professionals, including psychologists, occupational therapists, and speech therapists.[62][63][64] However, this type of therapy may not be easily accessible in some communities. If face-to-face options are unavailable, therapies may be delivered via videoconference or teleconference, or using online learning modules, although evidence for effectiveness is limited.[53][61]

Consider – alpha-2-adrenergic agonist

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics severe
Consider – 

alpha-2-adrenergic agonist

Additional treatment recommended for SOME patients in selected patient group

When medication is considered appropriate (i.e., after, or in addition to, behavioural therapy), alpha-2-adrenergic agonists are preferred as first-line pharmacological agents.[56] Although a lower efficacy is reported when used in tic disorders without comorbid conditions, clinicians and their patients may be more willing to try an alpha-2-adrenergic agonist for tics before moving to 'stronger' medications.[13][53][65][66] Options include oral or transdermal clonidine and oral guanfacine.[13][53][67]

Alpha-2-adrenergic agonists are associated with fewer and less serious adverse effects than antipsychotic (neuroleptic) medications, but caution should be used due to the potential risk of daytime fatigue. Heart rate and blood pressure should be monitored in all patients, and QTc interval monitored in high-risk patients taking guanfacine.[53]  

The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

clonidine: consult specialist for guidance on dose

OR

clonidine transdermal: consult specialist for guidance on dose

OR

guanfacine: consult specialist for guidance on dose

Consider – botulinum toxin type A injection

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics severe
Consider – 

botulinum toxin type A injection

Additional treatment recommended for SOME patients in selected patient group

Botulinum toxin type A injections can be used in adults and older adolescents with simple focal motor tics affecting the face or neck region, or with severely disabling or aggressive vocal tics.[53] This therapy is not suitable for patients who have complex tics involving multiple muscle groups. Injections are delivered directly into the affected muscles.

There is some evidence for a significant decrease in tics and premonitory urges with botulinum toxin type A injection compared with placebo in people with simple motor tics, but additional randomised controlled studies are needed.[68][69]

Referral to a movement disorders specialist is required. The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

botulinum toxin type A: consult specialist for guidance on dose

2nd line – alpha-2-adrenergic agonist

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics severe
2nd line – 

alpha-2-adrenergic agonist

When medication is considered appropriate (i.e., after, or in addition to, behavioural therapy), alpha-2-adrenergic agonists are preferred as first-line pharmacological agents.[56] Although a lower efficacy is reported when used in tic disorders without comorbid conditions, clinicians and their patients may be more willing to try an alpha-2-adrenergic agonist for tics before moving to 'stronger' medications.[13][53][65][66] Options include oral or transdermal clonidine and oral guanfacine.[13][53][67]

Alpha-2-adrenergic agonists are associated with fewer and less serious adverse effects than antipsychotic (neuroleptic) medications, but caution should be used due to the potential risk of daytime fatigue. Heart rate and blood pressure should be monitored in all patients, and QTc interval monitored in high-risk patients taking guanfacine.[53]  

The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

clonidine: consult specialist for guidance on dose

OR

clonidine transdermal: consult specialist for guidance on dose

OR

guanfacine: consult specialist for guidance on dose

Consider – behavioural therapy

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics severe
Consider – 

behavioural therapy

Additional treatment recommended for SOME patients in selected patient group

Comprehensive behavioural intervention for tics (CBIT) is a programme that includes habit reversal training, relaxation training, and a functional intervention to address situations that sustain or worsen tics. CBIT (if available) is recommended as an initial treatment option relative to other psychosocial/behavioural interventions and relative to medication.[53] Most children and adults showing an initial positive response to CBIT maintain treatment gains for at least 6 months. Effectiveness of CBIT appears similar to that of medication, and there is some evidence that effectiveness is greater for patients not taking anti-tic medication at the same time.[53][54][55][56] Most studies have been conducted with participants aged 9 years and older, but an open trial in children 5 to 8 years demonstrated beneficial effects of CBIT in this age group.[57]

Other behavioural therapies that may be used to treat tics if CBIT is not available include exposure and response prevention (ERP), habit reversal training (as a stand-alone therapy), and cognitive behavioural therapy.[53][58][59][60][61]

Behavioural therapies are delivered by trained professionals, including psychologists, occupational therapists, and speech therapists.[62][63][64] However, this type of therapy may not be easily accessible in some communities. If face-to-face options are unavailable, therapies may be delivered via videoconference or teleconference, or using online learning modules, although evidence for effectiveness is limited.[53][61]

Consider – botulinum toxin type A injection

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics severe
Consider – 

botulinum toxin type A injection

Additional treatment recommended for SOME patients in selected patient group

Botulinum toxin type A injections can be used in adults and older adolescents with simple focal motor tics affecting the face or neck region, or with severely disabling or aggressive vocal tics.[53] This therapy is not suitable for patients who have complex tics involving multiple muscle groups. Injections are delivered directly into the affected muscles.

There is some evidence for a significant decrease in tics and premonitory urges with botulinum toxin type A injection compared with placebo in people with simple motor tics, but additional randomised controlled studies are needed.[68][69]

Referral to a movement disorders specialist is required. The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

botulinum toxin type A: consult specialist for guidance on dose

3rd line – antipsychotic

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics severe
3rd line – 

antipsychotic

Atypical antipsychotics are preferred to typical antipsychotics because of their more favourable adverse-effect profile (e.g., lower risk of extrapyramidal symptoms and cardiac arrhythmias).[70]

Patients should be informed about potential adverse effects of antipsychotics, and suitable monitoring before and during treatment must be carried out.[53]

Aripiprazole is approved by the US Food and Drug Administration (FDA) for Tourette's syndrome, and has support for treating tic disorders in both children and adults.[53][67][71]

Risperidone is also effective for treating tic disorders.[53][67][71]

Atypical antipsychotics are associated with weight gain, sedation, metabolic syndrome, acute dystonic reactions, tardive dyskinesia, and neuroleptic malignant syndrome.

Among typical antipsychotics, haloperidol and pimozide have evidence of effectiveness for treating tics.[53] They are the only typical antipsychotics approved for the treatment of Tourette's syndrome in some countries.[72] Several movement disorder specialists use fluphenazine as the agent of choice, given its lower risk of adverse effects compared with haloperidol and pimozide, and its relative specificity for the dopamine D2 receptor; evidence of effectiveness is promising but limited.[12][53][73]

Potential adverse effects of typical antipsychotics include acute dystonic reactions, neuroleptic malignant syndrome, tardive dyskinesia, sedation, weight gain, and cardiac arrhythmias.[74] An ECG should be performed before starting pimozide and periodically thereafter. CYP2D6 genotyping should be done before increasing dose. CYP2D6 poor metabolisers will develop higher concentrations of pimozide, increasing the risk of prolonged QT.[75] Most studies on pimozide in children have been performed on children 12 years of age or older. There are only limited data on its use in younger children.

The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

aripiprazole: children ≥6 years of age and body weight <50 kg: 2 mg orally once daily initially for 2 days, increase gradually according to response, maximum 10 mg/day; children ≥6 years of age and body weight ≥50 kg and adults: 2 mg orally once daily initially for 2 days, increase gradually according to response, maximum 20 mg/day

OR

risperidone: consult specialist for guidance on dose

Secondary options

haloperidol: children 3-12 years of age: 0.025 to 0.05 mg/kg/day orally initially given in 2-3 divided doses, increase gradually according to response, maximum 0.15 mg/kg/day; children ≥12 years of age and adults: 0.5 to 2 mg orally two to three times daily initially, increase gradually according to response, usual dose 15 mg/day, maximum 100 mg/day

OR

pimozide: children ≥12 years of age: 0.05 mg/kg orally once daily at bedtime initially, increase gradually according to response, maximum 0.2 mg/kg/day or 10 mg/day; adults: 1-2 mg/day orally given in 1-2 divided doses, increase gradually according to response, maximum 0.2 mg/kg/day or 10 mg/day

OR

fluphenazine: consult specialist for guidance on dose

Consider – behavioural therapy

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics severe
Consider – 

behavioural therapy

Additional treatment recommended for SOME patients in selected patient group

Comprehensive behavioural intervention for tics (CBIT) is a programme that includes habit reversal training, relaxation training, and a functional intervention to address situations that sustain or worsen tics. CBIT (if available) is recommended as an initial treatment option relative to other psychosocial/behavioural interventions and relative to medication.[53] Most children and adults showing an initial positive response to CBIT maintain treatment gains for at least 6 months. Effectiveness of CBIT appears similar to that of medication, and there is some evidence that effectiveness is greater for patients not taking anti-tic medication at the same time.[53][54][55][56] Most studies have been conducted with participants aged 9 years and older, but an open trial in children 5 to 8 years demonstrated beneficial effects of CBIT in this age group.[57]

Other behavioural therapies that may be used to treat tics if CBIT is not available include exposure and response prevention (ERP), habit reversal training (as a stand-alone therapy), and cognitive behavioural therapy.[53][58][59][60][61]

Behavioural therapies are delivered by trained professionals, including psychologists, occupational therapists, and speech therapists.[62][63][64] However, this type of therapy may not be easily accessible in some communities. If face-to-face options are unavailable, therapies may be delivered via videoconference or teleconference, or using online learning modules, although evidence for effectiveness is limited.[53][61]

Consider – botulinum toxin type A injection

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics severe
Consider – 

botulinum toxin type A injection

Additional treatment recommended for SOME patients in selected patient group

Botulinum toxin type A injections can be used in adults and older adolescents with simple focal motor tics affecting the face or neck region, or with severely disabling or aggressive vocal tics.[53] This therapy is not suitable for patients who have complex tics involving multiple muscle groups. Injections are delivered directly into the affected muscles.

There is some evidence for a significant decrease in tics and premonitory urges with botulinum toxin type A injection compared with placebo in people with simple motor tics, but additional randomised controlled studies are needed.[68][69]

Referral to a movement disorders specialist is required. The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

botulinum toxin type A: consult specialist for guidance on dose

4th line – topiramate

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics severe
4th line – 

topiramate

Topiramate may be a useful alternative for tics in those who have comorbid obesity (due to the potential for minimal effects on weight associated with this medication), sleep difficulty, or migraine headaches.[53][76][77] 

The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder. Starting with a low dose at night and very slowly increasing the dose is recommended to limit adverse effects. Very low doses can be effective in some patients, while others may require higher doses.

Primary options

topiramate: consult specialist for guidance on dose

Consider – behavioural therapy

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics severe
Consider – 

behavioural therapy

Additional treatment recommended for SOME patients in selected patient group

Comprehensive behavioural intervention for tics (CBIT) is a programme that includes habit reversal training, relaxation training, and a functional intervention to address situations that sustain or worsen tics. CBIT (if available) is recommended as an initial treatment option relative to other psychosocial/behavioural interventions and relative to medication.[53] Most children and adults showing an initial positive response to CBIT maintain treatment gains for at least 6 months. Effectiveness of CBIT appears similar to that of medication, and there is some evidence that effectiveness is greater for patients not taking anti-tic medication at the same time.[53][54][55][56] Most studies have been conducted with participants aged 9 years and older, but an open trial in children 5 to 8 years demonstrated beneficial effects of CBIT in this age group.[57]

Other behavioural therapies that may be used to treat tics if CBIT is not available include exposure and response prevention (ERP), habit reversal training (as a stand-alone therapy), and cognitive behavioural therapy.[53][58][59][60][61]

Behavioural therapies are delivered by trained professionals, including psychologists, occupational therapists, and speech therapists.[62][63][64] However, this type of therapy may not be easily accessible in some communities. If face-to-face options are unavailable, therapies may be delivered via videoconference or teleconference, or using online learning modules, although evidence for effectiveness is limited.[53][61]

Consider – botulinum toxin type A injection

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
without ADHD or OCD: tics severe
Consider – 

botulinum toxin type A injection

Additional treatment recommended for SOME patients in selected patient group

Botulinum toxin type A injections can be used in adults and older adolescents with simple focal motor tics affecting the face or neck region, or with severely disabling or aggressive vocal tics.[53] This therapy is not suitable for patients who have complex tics involving multiple muscle groups. Injections are delivered directly into the affected muscles.

There is some evidence for a significant decrease in tics and premonitory urges with botulinum toxin type A injection compared with placebo in people with simple motor tics, but additional randomised controlled studies are needed.[68][69]

Referral to a movement disorders specialist is required. The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

botulinum toxin type A: consult specialist for guidance on dose

1st line – primary treatment for ADHD + psychoeducation and support

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
with ADHD as primary symptom complaint
1st line – 

primary treatment for ADHD + psychoeducation and support

It is important to recognise and treat comorbidities. If ADHD is the primary symptom complaint, this should be treated first. It should be recognised that treatment of ADHD may or may not increase tic burden. If behavioural issues are prominent, referral to a child psychologist and psychiatrist is appropriate.

See Attention deficit hyperactivity disorder in children and Attention deficit hyperactivity disorder in adults.

Stimulant medication for children with ADHD and tics has not been consistently proven to exacerbate tics, but individual patients may have this side effect.[86][87] If there is concern about tic exacerbation, some adjustment to the medication may be required. Alternative medication for ADHD may be tried. Atomoxetine has been reported to be effective for the treatment of ADHD in children with tic disorders, without worsening tic severity.[53][67][86][87]

Psychoeducation for the patient and their parents, teachers, and peers is the most important initial step in treating tics.[53] Patients and their parents should be reassured that the prognosis is favourable for the majority of people affected by tics. They should also be made aware of the tendency for tics to increase in times of stress, anxiety, transitions, and excitement. The family and the school should be advised to try not to focus on the presence of the tics.

2nd line – treatment for tics

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
with ADHD as primary symptom complaint
2nd line – 

treatment for tics

Treatment for non-severe tics and for severe tics for patients with ADHD is broadly similar to that for patients without ADHD or OCD (see above).

The alpha-2-adrenergic agonists clonidine and guanfacine are commonly used to treat tics in children with ADHD due to their beneficial effects on both conditions.[85][86][87]

Topiramate should be used with caution for patients with ADHD due to potential adverse effects on cognition.

1st line – primary treatment for OCD + psychoeducation and support

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
with OCD as primary symptom complaint
1st line – 

primary treatment for OCD + psychoeducation and support

It is important to recognise and treat comorbidities. If obsessive-compulsive disorder (OCD) is the primary symptom complaint, this should be treated first. If behavioural issues are prominent, referral to a child psychologist and psychiatrist is appropriate.

See Obsessive-compulsive disorder.

Selective serotonin-reuptake inhibitors (SSRIs), such as fluoxetine or sertraline, have been reported to be effective in the treatment of OCD and associated Tourette's syndrome.[89] However, there have also been contradictory reports of tic symptoms worsening after initiation of an SSRI.[90]

Psychoeducation for the patient and their parents, teachers, and peers is the most important initial step in treating tics.[53] Patients and their parents should be reassured that the prognosis is favourable for the majority of people affected by tics. They should also be made aware of the tendency for tics to increase in times of stress, anxiety, transitions, and excitement. The family and the school should be advised to try not to focus on the presence of the tics.

2nd line – behavioural therapy

Back
ACUTE
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symptoms interfering with activities of daily living: non-pregnant
|
with OCD as primary symptom complaint
2nd line – 

behavioural therapy

Comprehensive behavioural intervention for tics (CBIT) is a programme that includes habit reversal training, relaxation training, and a functional intervention to address situations that sustain or worsen tics. CBIT (if available) is recommended as an initial treatment option relative to other psychosocial/behavioural interventions and relative to medication.[53] Most children and adults showing an initial positive response to CBIT maintain treatment gains for at least 6 months. Effectiveness of CBIT appears similar to that of medication, and there is some evidence that effectiveness is greater for patients not taking anti-tic medication at the same time.[53][54][55][56] Most studies have been conducted with participants aged 9 years and older, but an open trial in children 5 to 8 years demonstrated beneficial effects of CBIT in this age group.[57]

Other behavioural therapies that may be used to treat tics if CBIT is not available include exposure and response prevention (ERP), habit reversal training (as a stand-alone therapy), and cognitive behavioural therapy.[53][58][59][60][61]

Behavioural therapies are delivered by trained professionals, including psychologists, occupational therapists, and speech therapists.[62][63][64] However, this type of therapy may not be easily accessible in some communities. If face-to-face options are unavailable, therapies may be delivered via videoconference or teleconference, or using online learning modules, although evidence for effectiveness is limited.[53][61]

Consider – botulinum toxin type A injection

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
with OCD as primary symptom complaint
Consider – 

botulinum toxin type A injection

Additional treatment recommended for SOME patients in selected patient group

Botulinum toxin type A injections can be used in adults and older adolescents with simple focal motor tics affecting the face or neck region, or with severely disabling or aggressive vocal tics.[53] This therapy is not suitable for patients who have complex tics involving multiple muscle groups. Injections are delivered directly into the affected muscles.

There is some evidence for a significant decrease in tics and premonitory urges with botulinum toxin type A injection compared with placebo in people with simple motor tics, but additional randomised controlled studies are needed.[68][69]

Referral to a movement disorders specialist is required. The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

botulinum toxin type A: consult specialist for guidance on dose

3rd line – antipsychotic

Back
ACUTE
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symptoms interfering with activities of daily living: non-pregnant
|
with OCD as primary symptom complaint
3rd line – 

antipsychotic

Antipsychotic medication is more likely to be first choice medication for treating tics in patients with OCD, as antipsychotics have efficacy as adjunctive treatment to SSRIs for OCD, and can therefore be helpful for both tic and OCD symptoms.[88] 

Atypical antipsychotics are preferred to typical antipsychotics because of their more favourable adverse-effect profile (e.g., lower risk of extrapyramidal symptoms and cardiac arrhythmias).[70]

Patients should be informed about potential adverse effects of antipsychotics, and suitable monitoring before and during treatment must be carried out.[53]

Aripiprazole is approved by the US Food and Drug Administration (FDA) for Tourette's syndrome, and has support for treating tic disorders in both children and adults.[53][67][71]

Risperidone is also effective for treating tic disorders.[53][67][71]

Atypical antipsychotics are associated with weight gain, sedation, metabolic syndrome, acute dystonic reactions, tardive dyskinesia, and neuroleptic malignant syndrome.

Among typical antipsychotics, haloperidol and pimozide have evidence of effectiveness for treating tics.[53] They are the only typical antipsychotics approved for the treatment of Tourette's syndrome in some countries.[72] Several movement disorder specialists use fluphenazine as the agent of choice, given its lower risk of adverse effects compared with haloperidol and pimozide, and its relative specificity for the dopamine D2 receptor; evidence of effectiveness is promising but limited.[12][53][73]

Potential adverse effects of typical antipsychotics include acute dystonic reactions, neuroleptic malignant syndrome, tardive dyskinesia, sedation, weight gain, and cardiac arrhythmias.[74] An ECG should be performed before starting pimozide and periodically thereafter. CYP2D6 genotyping should be done before increasing dose. CYP2D6 poor metabolisers will develop higher concentrations of pimozide, increasing the risk of prolonged QT.[75] Most studies on pimozide in children have been performed on children 12 years of age or older. There are only limited data on its use in younger children.

The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

aripiprazole: children ≥6 years of age and body weight <50 kg: 2 mg orally once daily initially for 2 days, increase gradually according to response, maximum 10 mg/day; children ≥6 years of age and body weight ≥50 kg and adults: 2 mg orally once daily initially for 2 days, increase gradually according to response, maximum 20 mg/day

OR

risperidone: consult specialist for guidance on dose

Secondary options

haloperidol: children 3-12 years of age: 0.025 to 0.05 mg/kg/day orally initially given in 2-3 divided doses, increase gradually according to response, maximum 0.15 mg/kg/day; children ≥12 years of age and adults: 0.5 to 2 mg orally two to three times daily initially, increase gradually according to response, usual dose 15 mg/day, maximum 100 mg/day

OR

pimozide: children ≥12 years of age: 0.05 mg/kg orally once daily at bedtime initially, increase gradually according to response, maximum 0.2 mg/kg/day or 10 mg/day; adults: 1-2 mg/day orally given in 1-2 divided doses, increase gradually according to response, maximum 0.2 mg/kg/day or 10 mg/day

OR

fluphenazine: consult specialist for guidance on dose

Consider – behavioural therapy

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
with OCD as primary symptom complaint
Consider – 

behavioural therapy

Additional treatment recommended for SOME patients in selected patient group

Comprehensive behavioural intervention for tics (CBIT) is a programme that includes habit reversal training, relaxation training, and a functional intervention to address situations that sustain or worsen tics. CBIT (if available) is recommended as an initial treatment option relative to other psychosocial/behavioural interventions and relative to medication.[53] Most children and adults showing an initial positive response to CBIT maintain treatment gains for at least 6 months. Effectiveness of CBIT appears similar to that of medication, and there is some evidence that effectiveness is greater for patients not taking anti-tic medication at the same time.[53][54][55][56] Most studies have been conducted with participants aged 9 years and older, but an open trial in children 5 to 8 years demonstrated beneficial effects of CBIT in this age group.[57]

Other behavioural therapies that may be used to treat tics if CBIT is not available include exposure and response prevention (ERP), habit reversal training (as a stand-alone therapy), and cognitive behavioural therapy.[53][58][59][60][61]

Behavioural therapies are delivered by trained professionals, including psychologists, occupational therapists, and speech therapists.[62][63][64] However, this type of therapy may not be easily accessible in some communities. If face-to-face options are unavailable, therapies may be delivered via videoconference or teleconference, or using online learning modules, although evidence for effectiveness is limited.[53][61]

Consider – botulinum toxin type A injection

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
with OCD as primary symptom complaint
Consider – 

botulinum toxin type A injection

Additional treatment recommended for SOME patients in selected patient group

Botulinum toxin type A injections can be used in adults and older adolescents with simple focal motor tics affecting the face or neck region, or with severely disabling or aggressive vocal tics.[53] This therapy is not suitable for patients who have complex tics involving multiple muscle groups. Injections are delivered directly into the affected muscles.

There is some evidence for a significant decrease in tics and premonitory urges with botulinum toxin type A injection compared with placebo in people with simple motor tics, but additional randomised controlled studies are needed.[68][69]

Referral to a movement disorders specialist is required. The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

botulinum toxin type A: consult specialist for guidance on dose

3rd line – alpha-2-adrenergic agonist

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
with OCD as primary symptom complaint
3rd line – 

alpha-2-adrenergic agonist

Options include oral or transdermal clonidine and oral guanfacine.[13][53][67] Alpha-2-adrenergic agonists are associated with fewer and less serious adverse effects than antipsychotic (neuroleptic) medications, but caution should be used due to the potential risk of daytime fatigue. Heart rate and blood pressure should be monitored in all patients, and QTc interval monitored in high-risk patients taking guanfacine.[53]  

The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

clonidine: consult specialist for guidance on dose

OR

clonidine transdermal: consult specialist for guidance on dose

OR

guanfacine: consult specialist for guidance on dose

Consider – behavioural therapy

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
with OCD as primary symptom complaint
Consider – 

behavioural therapy

Additional treatment recommended for SOME patients in selected patient group

Comprehensive behavioural intervention for tics (CBIT) is a programme that includes habit reversal training, relaxation training, and a functional intervention to address situations that sustain or worsen tics. CBIT (if available) is recommended as an initial treatment option relative to other psychosocial/behavioural interventions and relative to medication.[53] Most children and adults showing an initial positive response to CBIT maintain treatment gains for at least 6 months. Effectiveness of CBIT appears similar to that of medication, and there is some evidence that effectiveness is greater for patients not taking anti-tic medication at the same time.[53][54][55][56] Most studies have been conducted with participants aged 9 years and older, but an open trial in children 5 to 8 years demonstrated beneficial effects of CBIT in this age group.[57]

Other behavioural therapies that may be used to treat tics if CBIT is not available include exposure and response prevention (ERP), habit reversal training (as a stand-alone therapy), and cognitive behavioural therapy.[53][58][59][60][61]

Behavioural therapies are delivered by trained professionals, including psychologists, occupational therapists, and speech therapists.[62][63][64] However, this type of therapy may not be easily accessible in some communities. If face-to-face options are unavailable, therapies may be delivered via videoconference or teleconference, or using online learning modules, although evidence for effectiveness is limited.[53][61]

Consider – botulinum toxin type A injection

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
with OCD as primary symptom complaint
Consider – 

botulinum toxin type A injection

Additional treatment recommended for SOME patients in selected patient group

Botulinum toxin type A injections can be used in adults and older adolescents with simple focal motor tics affecting the face or neck region, or with severely disabling or aggressive vocal tics.[53] This therapy is not suitable for patients who have complex tics involving multiple muscle groups. Injections are delivered directly into the affected muscles.

There is some evidence for a significant decrease in tics and premonitory urges with botulinum toxin type A injection compared with placebo in people with simple motor tics, but additional randomised controlled studies are needed.[68][69]

Referral to a movement disorders specialist is required. The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

botulinum toxin type A: consult specialist for guidance on dose

4th line – topiramate

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
with OCD as primary symptom complaint
4th line – 

topiramate

Topiramate may be a useful alternative for tics in those who have comorbid obesity (due to the potential for minimal effects on weight associated with this medication), sleep difficulty, or migraine headaches.[53][76][77] 

The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder. Starting with a low dose at night and very slowly increasing the dose is recommended to limit adverse effects. Very low doses can be effective in some patients, while others may require higher doses.

Primary options

topiramate: consult specialist for guidance on dose

Consider – behavioural therapy

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
with OCD as primary symptom complaint
Consider – 

behavioural therapy

Additional treatment recommended for SOME patients in selected patient group

Comprehensive behavioural intervention for tics (CBIT) is a programme that includes habit reversal training, relaxation training, and a functional intervention to address situations that sustain or worsen tics. CBIT (if available) is recommended as an initial treatment option relative to other psychosocial/behavioural interventions and relative to medication.[53] Most children and adults showing an initial positive response to CBIT maintain treatment gains for at least 6 months. Effectiveness of CBIT appears similar to that of medication, and there is some evidence that effectiveness is greater for patients not taking anti-tic medication at the same time.[53][54][55][56] Most studies have been conducted with participants aged 9 years and older, but an open trial in children 5 to 8 years demonstrated beneficial effects of CBIT in this age group.[57]

Other behavioural therapies that may be used to treat tics if CBIT is not available include exposure and response prevention (ERP), habit reversal training (as a stand-alone therapy), and cognitive behavioural therapy.[53][58][59][60][61]

Behavioural therapies are delivered by trained professionals, including psychologists, occupational therapists, and speech therapists.[62][63][64] However, this type of therapy may not be easily accessible in some communities. If face-to-face options are unavailable, therapies may be delivered via videoconference or teleconference, or using online learning modules, although evidence for effectiveness is limited.[53][61]

Consider – botulinum toxin type A injection

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
with OCD as primary symptom complaint
Consider – 

botulinum toxin type A injection

Additional treatment recommended for SOME patients in selected patient group

Botulinum toxin type A injections can be used in adults and older adolescents with simple focal motor tics affecting the face or neck region, or with severely disabling or aggressive vocal tics.[53] This therapy is not suitable for patients who have complex tics involving multiple muscle groups. Injections are delivered directly into the affected muscles.

There is some evidence for a significant decrease in tics and premonitory urges with botulinum toxin type A injection compared with placebo in people with simple motor tics, but additional randomised controlled studies are needed.[68][69]

Referral to a movement disorders specialist is required. The doses of all drugs used for the management of tic disorder should be provided by a specialist who is experienced in the management of this disorder.

Primary options

botulinum toxin type A: consult specialist for guidance on dose

1st line – combination therapy with specialist referral

Back
ACUTE
|
symptoms interfering with activities of daily living: non-pregnant
|
with ADHD and OCD
1st line – 

combination therapy with specialist referral

Approximately 25% of patients have both ADHD and obsessive-compulsive disorder (OCD) in addition to tics.[91] Specialist referral is indicated. Treatment is patient-led with regard to prioritisation of which condition to focus on treating first. 

severe tics refractory to behavioural and pharmacological therapies

1st line – deep brain stimulation

Back
ACUTE
|
severe tics refractory to behavioural and pharmacological therapies
1st line – 

deep brain stimulation

Deep brain stimulation (DBS) may be considered as an option for patients with severe disabling tics (i.e., unable to function in everyday activities such as school or work, or at risk for serious injury) that are resistant to behavioural and pharmacological therapies.[53]

Small case series and cross-over studies of DBS using several brain targets (i.e., globus pallidus internus, nucleus accumbens, thalamus) have shown contradictory results; information from randomised controlled trials is limited.[53][67][92][93][94] In some cases, comorbid OCD, ADHD, and/or mood disturbances improved in addition to the tic symptoms.[92][95]

Patients eligible for DBS (i.e., with severe tics refractory to behavioural therapy and several types of medication) must have a multidisciplinary evaluation to establish whether potential benefits outweigh the risks, and should be screened preoperatively and followed postoperatively for psychiatric disorders.[53][95]

symptoms interfering with activities of daily living: pregnant

1st line – referral to movement disorder specialist and high-risk obstetrician

Back
ACUTE
|
symptoms interfering with activities of daily living: pregnant
1st line – 

referral to movement disorder specialist and high-risk obstetrician

Tics may occur for the first time in pregnancy. Treatment (including both behavioural and pharmacological interventions) may be considered if the patient has significant symptoms that interfere in daily activities. If treatment is required, the patient should be referred to a movement disorder specialist and a high-risk obstetrician.

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