From the Guidelines
For the treatment of tics, alpha-2 adrenergic agonists such as clonidine or guanfacine are recommended as first-line treatments due to their favorable side effect profiles, with antipsychotics like risperidone, aripiprazole, or haloperidol considered for more severe cases 1.
Medication Options
- Clonidine: starting at 0.05mg daily, gradually increasing to 0.1-0.4mg daily divided into 3-4 doses
- Guanfacine: starting at 0.5mg daily, increasing to 1-4mg daily
- Risperidone: 0.5-3mg daily
- Aripiprazole: 2-15mg daily
- Haloperidol: 0.5-5mg daily
Treatment Approach
Treatment should start at the lowest possible dose and increase gradually while monitoring for side effects. These medications work by modulating dopamine and norepinephrine pathways in the brain that regulate movement control.
Behavioral Therapies
Behavioral therapies like Comprehensive Behavioral Intervention for Tics (CBIT) or habit reversal training should be considered alongside medication.
Side Effects
Side effects to monitor include sedation and hypotension with alpha agonists, and weight gain, metabolic changes, and movement disorders with antipsychotics. Regular follow-up is essential to assess effectiveness and manage side effects.
Treatment Duration
Treatment duration varies; some patients require long-term therapy while others may attempt medication tapering after 6-12 months of tic control. According to the study by 1, pimozide was superior to haloperidol in efficacy and side effects for the treatment of Tourette syndrome, but this study is outdated and more recent evidence from 1 supports the use of alpha-2 adrenergic agonists and antipsychotics for the treatment of tics.
From the FDA Drug Label
CONTRAINDICATIONS 1. Pimozide is contraindicated in the treatment of simple tics or tics other than those associated with Tourette’s Disorder.
- Pimozide is used for the treatment of tics associated with Tourette’s Disorder, but it is contraindicated for simple tics or tics other than those associated with Tourette’s Disorder 2.
- The use of pimozide for tics is limited to those associated with Tourette’s Disorder.
From the Research
Overview of Drugs for Tics
- The pharmacological treatment of tic disorders and Tourette Syndrome (TS) involves various medications, including risperidone, tiapride, aripiprazole, and pimozide 3.
- Alpha-adrenoceptor agonists, such as guanfacine and clonidine, are often recommended as initial pharmacotherapy due to their established evidence base for efficacy and tolerability 4.
First-Line and Second-Line Treatments
- Risperidone and tiapride are recommended as first-line treatments for tics, with aripiprazole and pimozide as second-line options 3.
- Clonidine and guanfacine are considered better tolerated than antipsychotics but may be less effective 5.
Treatment of Comorbid Conditions
- For TS patients with comorbid attention deficit hyperactivity disorder (ADHD), medications such as atomoxetine, stimulants, or clonidine may be considered 3, 6.
- In cases of mild to moderate tics associated with obsessive-compulsive symptoms, depression, or anxiety, sulpiride monotherapy or a combination of risperidone and a selective serotonin reuptake inhibitor may be helpful 3.
Quality of Evidence and Treatment Decisions
- The quality of evidence for pharmacological treatments of TS is often limited by the scarcity of large, randomized, double-blind, placebo-controlled trials 3, 5.
- Treatment decisions should be guided by individual patient needs, symptom severity, and the presence of comorbidities, with a focus on "symptom-targeted" and personalized approaches 6, 7.