What are the medications for treating tics (involuntary muscle contractions)?

From the Guidelines

The most effective treatment for tics, based on the latest evidence, typically involves the use of alpha-2 adrenergic agonists like clonidine (0.1-0.3 mg/day) and guanfacine (1-4 mg/day) as first-line treatments, especially for mild to moderate tics. These medications work by reducing norepinephrine activity in the brain, which helps decrease tic frequency and severity with fewer side effects than antipsychotics 1.

Treatment Options

For more severe tics, antipsychotics such as risperidone (0.5-3 mg/day), aripiprazole (2-15 mg/day), or haloperidol (0.5-5 mg/day) may be prescribed. These work by blocking dopamine receptors, effectively reducing tic symptoms, though they carry more significant side effects including weight gain and metabolic changes.

• Clonidine and guanfacine are preferred for their relatively safer side effect profile and efficacy in reducing tic symptoms.
• Antipsychotics are considered for more severe cases due to their potent dopamine receptor blocking action.
• Botulinum toxin injections can be useful for focal motor tics, offering a targeted approach to symptom management.

Non-Pharmacological Approaches

Behavioral therapy, particularly Comprehensive Behavioral Intervention for Tics (CBIT), offers a non-pharmacological approach that teaches patients to recognize premonitory urges and develop competing responses. This method is beneficial for patients who prefer to avoid medication or have mild tics.

• CBIT has been shown to be effective in reducing tic severity and improving quality of life.
• It is often used in conjunction with medication for optimal outcomes.

Individualized Treatment

Treatment should be individualized based on tic severity, impact on daily functioning, and the patient's tolerance of potential side effects. Regular follow-up and adjustment of treatment plans are crucial to ensure the best possible outcomes for patients with tics.

• The choice of medication and dosage should be tailored to the patient's specific needs and response to treatment.
• Close monitoring for side effects and adjustments to the treatment plan as needed are essential for minimizing morbidity and improving quality of life.

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-2 adrenergic agonists, such as clonidine and guanfacine, are also used to treat tics, particularly in patients with mild symptoms or comorbid attention deficit hyperactivity disorder (ADHD) 4, 5.
• The choice of medication depends on the individual's specific needs and the presence of comorbid conditions, such as ADHD or obsessive-compulsive disorder 3, 5.

First-Line and Second-Line Treatments

• Risperidone and tiapride are recommended as first-line treatments for tics due to their efficacy and relatively low risk of adverse reactions 3.
• Aripiprazole and pimozide are considered second-line treatments, with aripiprazole showing promising results but limited data 3, 6.
• Clonidine and guanfacine are often used as initial pharmacotherapy due to their established evidence base and tolerability 4, 6.

Treatment of Comorbid Conditions

• In patients with TS and comorbid ADHD, medications such as atomoxetine, stimulants, or clonidine may be considered 3, 5.
• For patients with mild to moderate tics and comorbid obsessive-compulsive symptoms, depression, or anxiety, sulpiride monotherapy may be helpful 3.
• In more severe cases, the combination of risperidone and a selective serotonin reuptake inhibitor may be used 3.

Emerging Treatment Paradigms

• Newer medications, such as topiramate and vesicular monoamine transporter-2 inhibitors, are being considered for the treatment of tics, particularly in cases where other treatments are ineffective 7.
• Botulinum toxin injections may be used for focal motor tics, and cannabinoids may be considered in adults with treatment-resistant tics 7.