Approach

Most tics in children are mild and do not require treatment. Even patients with mild Tourette syndrome (Tourette disorder) may not require treatment.

Treatment is indicated for patients whose tics interfere with activities of daily living, social interactions, or school or job performance. The main goal is to optimize the quality of life for the patient through reduction of tics and improvement of behavioral issues, if present. Most physicians use behavioral therapy and/or pharmacotherapy to treat tics that affect quality of life and activities of daily living. Treatment should be individualized and collaborative, and take into account comorbid disorders.[54]

Initial measures for all patients

Psychoeducation for the patient and their parents, teachers, and peers is the most important initial step.[54] Patients and their parents should be reassured that the prognosis is favorable 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 behavior disorders.[54]

Behavioral therapies

Behavioral therapies are an essential component in the treatment of tics. Comprehensive behavioral intervention for tics (CBIT) is a program 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/behavioral interventions and relative to medication.[54] 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.[54][55][56][57] Most studies have been conducted with participants ages 9 years and older, but an open trial in children 5 to 8 years demonstrated beneficial effects of CBIT in this age group.[58]

Other behavioral 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 behavioral therapy.[54][59][60][61][62]

Behavioral therapies are delivered by trained professionals, including psychologists, occupational therapists, and speech therapists.[63][64][65] 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.[54][62]

There is insufficient evidence to support the use of physical exercise and/or dietary interventions in the treatment of tic disorders.[54][57]

Pharmacotherapy

If pharmacologic therapy is indicated and desired by the patient and family, treatment should be chosen based on the adverse-effect profile and presence of comorbid conditions (including pregnancy; see below).[2] Because many patients with tics are children, dosing for an individual patient should be based on the patient's age and weight. The doses of all drugs should be provided by a specialist who is experienced in the management of tic disorders.

Pharmacologic options include alpha-2-adrenergic agonists, antipsychotics, onabotulinumtoxinA injections, and topiramate.

Alpha-2-adrenergic agonists

  • When medication is considered appropriate (i.e., after, or in addition to, behavioral therapy), alpha-2-adrenergic agonists are preferred as first-line pharmacologic agents.[57] 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][54][66][67]

  • Options include oral or transdermal clonidine and oral guanfacine.[13][54][68] 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.[54]

Botulinum toxin injections

  • OnabotulinumtoxinA 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.[54] 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 onabotulinumtoxinA injection compared with placebo in people with simple motor tics, but additional randomized controlled studies are needed.[69][70]

  • Referral to a movement disorders specialist is required.

Antipsychotics

Because of the risk of adverse effects, antipsychotics are mostly used if alpha-2-adrenergic agonists are either ineffective or poorly tolerated.[57] They are not suitable for treating non-severe tics. Patients should be informed about potential adverse effects, and suitable monitoring before and during treatment must be carried out.[54]

  • Atypical antipsychotics

    • Atypical antipsychotics are preferred to typical antipsychotics because of their more favorable adverse-effect profile (e.g., lower risk of extrapyramidal symptoms and cardiac arrhythmias).[71]

    • Aripiprazole is approved by the Food and Drug Administration (FDA) for Tourette syndrome, and has support for treating tic disorders in both children and adults.[54][68][72]

    • Risperidone is also effective for treating tic disorders.[54][68][72]

    • Atypical antipsychotics are associated with weight gain, sedation, metabolic syndrome, acute dystonic reactions, tardive dyskinesia, and neuroleptic malignant syndrome. Patients should be treated with the lowest, most effective dose.

  • Typical antipsychotics

    • Haloperidol and pimozide have evidence of effectiveness for treating tics.[54] They are the only typical antipsychotics approved for the treatment of Tourette syndrome in some countries.[73]​ 

    • 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][54][74]​​

    • Potential adverse effects of typical antipsychotics include acute dystonic reactions, neuroleptic malignant syndrome, tardive dyskinesia, sedation, weight gain, and cardiac arrhythmias.[75]​​

    • An ECG should be performed before starting pimozide and periodically thereafter. CYP2D6 genotyping should be done before increasing dose. CYP2D6 poor metabolizers will develop higher concentrations of pimozide, increasing the risk of prolonged QT.[76]​ 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.

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.[54][77][78] 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.

Other medications

Several small uncontrolled studies suggested the use of baclofen for treating tic disorders, although the evidence appears to be weak at best, and this drug is not used in practice.[79][80]

Benzodiazepines such as clonazepam have been reported to be effective in the treatment of tic disorders.[81] However, there have been no systematic studies to support the use of this medication and the potential for tolerance and/or abuse should be considered. They are therefore considered as a last resort.

Tetrabenazine is a type of dopamine antagonist that works by depleting presynaptic dopamine.[82] There is some evidence for tic improvement in patients with Tourette syndrome treated with tetrabenazine over 2 years; however, no randomized controlled trials of tetrabenazine for tics have been performed.[83] Tetrabenazine has been reported to cause drug-induced parkinsonism, and can cause depression and suicidal ideation.[84] Deutetrabenazine and valbenazine, two medications with a similar mechanism of action to tetrabenazine, failed to demonstrate significant effectiveness compared with placebo for the treatment of tics in multiple trials.[85]

Additional considerations for patients with coexisting ADHD and/or OCD

It is important to recognize and treat comorbidities, the most common of which are ADHD and OCD.[54] For many patients, addressing and treating their comorbidities may be more helpful than just controlling tics alone. If behavioral issues are prominent, referral to a child psychologist and psychiatrist is appropriate.

ADHD

Treatment for tics for patients with ADHD is broadly similar to that for patients without ADHD. 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.[86][87][88] Topiramate should be used with caution for patients with ADHD due to potential adverse effects on cognition.

Stimulant medication for children with ADHD and tics has not been consistently proven to exacerbate tics, but individual patients may have this side effect.[87][88] 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.[54][68][87][88]

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

OCD

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 selective serotonin-reuptake inhibitors (SSRIs) for OCD, and can therefore be helpful for both tic and OCD symptoms.[89]

SSRIs, such as fluoxetine or sertraline, have been reported to be effective in the treatment of OCD and associated Tourette syndrome.[90] However, there have also been contradictory reports of tic symptoms worsening after initiation of an SSRI.[91]

See Obsessive-compulsive disorder.

ADHD and OCD

Approximately 25% of patients have both ADHD and OCD in addition to tics.[92] Specialist referral is indicated. Treatment is patient-led with regard to prioritization of which condition to focus on treating first.

Deep brain stimulation for patients with severe tics refractory to behavioral and pharmacologic therapies

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 behavioral and pharmacologic therapies.[54]

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 randomized controlled trials is limited.[54][68][93][94][95] In some cases, comorbid OCD, ADHD, and/or mood disturbances improved in addition to the tic symptoms.[93][96] 

Patients eligible for DBS (i.e., with severe tics refractory to behavioral 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.[54][96]

Management of tics in pregnancy

Tics may occur for the first time in pregnancy. Treatment (including both behavioral and pharmacologic interventions) may be considered if the patient has significant symptoms that interfere with 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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