New guidelines from the American Academy of Neurology (AAN) on the management of Tourette syndrome and other chronic tic disorders reflect a growing interest in behavioral treatments and neuromodulation. The guidelines were published in the May 7, 2019, issue of Neurology and presented at the 2019 American Academy of Neurology Annual Meeting in Philadelphia.1
“Tourette syndrome and other chronic tic disorders can be of great concern to the person diagnosed and their family, so it is important that doctors let those affected know that tics may improve with time,” said guideline lead author Tamara Pringsheim, MD, MSc, of the University of Calgary in Alberta, Canada. “Treatments can help decrease tic frequency and severity, but they rarely eliminate all tics.”2
An acceptable management approach consists of watchful waiting and patient education for those with tics that do not cause physical impairment, pain, emotional distress, or social embarrassment, according to the authors of the guidelines. Most children with tics experience an improvement in symptoms in late adolescence.
For patients with symptoms that interfere with daily activities, the guidelines recommend Comprehensive Behavioral Intervention for Tics (CBIT) as first-line therapy. CBIT, which includes relaxation training, habit-reversal training, and behavioral therapy, has been shown to be effective in both children and adults and has no significant adverse effects.
Because comorbid neurodevelopmental and psychiatric conditions—particularly obsessive-compulsive disorder and attention-deficit/hyperactivity disorder (ADHD)—are common in patients with tics, the guidelines recommend evaluation for these disorders. For some patients, alpha-2 adrenergic agonists (clonidine and guanfacine) can reduce symptoms of both tic disorders and ADHD.
Antipsychotics can reduce tic severity but are associated with extrapyramidal, hormonal, and metabolic adverse effects. If the benefits of antipsychotic therapy outweigh the risks, physicians should start with the lowest effective dose and monitor patients for adverse effects. When therapy needs to be discontinued, gradual tapering of the dosage is recommended.
Botulinum toxin injections can also reduce tic severity in adolescents and adults. The most common adverse effects are weakness and hypophonia, and treatment needs to be repeated after approximately 12 to 16 weeks. Topiramate may be an option for patients with mild tics who have not have good results from or who have not tolerated other treatments; however, it is associated with adverse effects, such as cognitive and language problems, somnolence, and weight loss.
Adults with severe Tourette syndrome that is resistant to medical and behavioral therapy may benefit from deep brain stimulation (DBS). The guidelines caution that there is limited evidence from randomized clinical trials to support DBS, and few operations are performed each year.
Some adults with Tourette syndrome self-medicate with cannabis products. Limited data suggest that delta-9-tetrahydrocannabinol (dronabinol) may reduce the severity of tics in adults. Because cannabis use is illegal or restricted in many states, the guidelines advise that physicians follow local laws on medical marijuana. Cannabis-based medications should be avoided in children, adolescents, women who are pregnant or breastfeeding, and persons with psychosis.
1. Pringsheim T, Okun MS, Holler-Managan Y, et al. Practice guideline: the treatment of tics in people with Tourette syndrome and chronic tic disorders. Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. Published online May 6, 2019. Doi: 10.1212/WNL.0000000000007466
2. New AAN guideline for treating Tourette syndrome and other chronic tic disorders [press release]. Minneapolis, MN: American Academy of Neurology. May 6, 2019. Accessed May 7, 2019.