Pharmacologic Management of Tics in Children
For children with tics requiring medication, alpha-2 adrenergic agonists (clonidine or guanfacine) should be tried first, followed by atypical antipsychotics (aripiprazole or risperidone) if tics remain problematic. 1
When to Consider Medication
Medication is indicated when:
- Tics cause functional impairment in daily activities
- Social problems arise from tics
- Quality of life is significantly affected
- Behavioral interventions (CBIT) have failed or are unavailable
Do not medicate mild transient tic disorders - these are self-limited and affect 4-24% of elementary school children, typically resolving within one year 2.
First-Line Pharmacologic Treatment
Alpha-2 Adrenergic Agonists
Start with clonidine or guanfacine as first-line agents 1. These medications have:
- Lower side effect burden compared to antipsychotics
- Evidence of efficacy in reducing tics
- Additional benefit if comorbid ADHD is present
Dosing considerations:
Critical caveat: Must taper these medications when discontinuing - never stop abruptly due to risk of rebound hypertension 4. Monitor for somnolence, hypotension, bradycardia, and potential cognitive dulling 5.
Second-Line Treatment
Atypical Antipsychotics
If alpha-2 agonists fail or tics remain severe, move to atypical antipsychotics, specifically aripiprazole or risperidone 2, 6, 7.
Aripiprazole:
- Dosing: 5-15 mg/day flexibly dosed 3
- Better tolerated than first-generation antipsychotics
- Lower risk of extrapyramidal symptoms
Risperidone:
- Dosing: 0.5-3.5 mg/day 3
- Strong evidence for efficacy in tic reduction
- 69% positive response vs 12% placebo 3
Monitor closely for:
- Weight gain (most common and problematic)
- Sedation, increased appetite
- Extrapyramidal symptoms (though less than typical antipsychotics)
- Metabolic changes
FDA-Approved Options
Only haloperidol and pimozide have FDA approval for Tourette syndrome 2. However, one randomized controlled trial showed pimozide superior to haloperidol in both efficacy and side effects 2. Despite FDA approval, these typical antipsychotics are generally reserved for severe, refractory cases due to higher risk of extrapyramidal symptoms, particularly in children 5.
Special Populations
Tics with Comorbid ADHD
This changes the algorithm significantly:
- If ADHD symptoms predominate, stimulants can be used despite historical concerns 1
- Multiple double-blind placebo-controlled studies show stimulants do not worsen tics in the majority of patients 1
- If tics remain problematic on stimulants, add alpha-2 agonists (clonidine or guanfacine) to the stimulant 1
- This combination addresses both conditions effectively
Tics with Comorbid OCD
Aripiprazole plus sertraline is the preferred combination for moderate-to-severe tic disorders with comorbid OCD 8. Sertraline alone is recommended when OCD symptoms predominate 8.
Tics with Comorbid Anxiety/Depression
Sertraline is the preferred agent across all severities of tic disorders when anxiety or depression is present 8.
Treatment Algorithm Summary
- Mild transient tics: No medication - reassurance and monitoring only
- Moderate-to-severe tics without comorbidity:
- First: Alpha-2 agonists (clonidine or guanfacine)
- Second: Atypical antipsychotics (aripiprazole or risperidone)
- Tics + ADHD:
- Stimulant trial first
- Add alpha-2 agonist if tics persist
- Tics + OCD: Aripiprazole + sertraline
- Tics + Anxiety/Depression: Sertraline + tic medication as needed
Critical Pitfalls to Avoid
Do not use typical antipsychotics (haloperidol) as first-line despite FDA approval - children have increased sensitivity to extrapyramidal symptoms 5. Reserve these for severe, treatment-refractory cases only.
Do not withhold stimulants in children with both ADHD and tics - the evidence clearly shows stimulants are safe and effective in this population, with proper informed consent 1.
Do not abruptly discontinue alpha-2 agonists - always taper to prevent rebound hypertension 4.
Do not prescribe medication for behavioral problems alone without establishing a clear DSM-5 diagnosis of a tic disorder 5.