What are the treatment options for a patient with tics?

Treatment Options for Tics

First-line treatment for tics should be behavioral therapy, specifically Comprehensive Behavioral Intervention for Tics (CBIT) or Habit Reversal Training (HRT), which have demonstrated efficacy without the side effects of pharmacological interventions. 1, 2

Diagnostic Considerations

Before initiating treatment, it's important to differentiate between different types of tics:

• Simple tics: Brief, sudden movements like eye blinking or throat clearing
• Complex tics: Coordinated patterns of movements
• Vocal tics: Sounds, words, or phrases produced involuntarily
• Tic disorders: Including transient tic disorder (lasting <1 year), chronic motor or vocal tic disorder (lasting >1 year), and Tourette syndrome (multiple motor and at least one vocal tic)

Treatment Algorithm

Step 1: Behavioral Interventions (First-Line)

• Comprehensive Behavioral Intervention for Tics (CBIT): Combines habit reversal training with functional interventions to identify and neutralize tic-related environmental factors 1

  • Demonstrated acute and durable efficacy in large-scale randomized controlled trials
  • Effective when delivered in person or via telehealth
  • Works with or without comorbid conditions

• Habit Reversal Training (HRT): Teaches patients to recognize premonitory urges and perform competing responses 3

  • Requires a cooperative patient and presence of premonitory urges
  • Family commitment enhances success

• Exposure and Response Prevention (ERP): Patients are exposed to premonitory urges while suppressing tics 3

  • Equally beneficial compared to HRT in face-to-face treatment

Step 2: Pharmacological Interventions (When Behavioral Therapy Is Insufficient)

For patients who don't respond adequately to behavioral interventions, a two-tier medication approach is recommended:

First-Tier Medications:

• Alpha-2 adrenergic agonists (clonidine, guanfacine)
  • Particularly useful for patients with comorbid ADHD and tics 4, 5
  • Lower side effect profile than neuroleptics
  • Recommended for milder tics 6

Second-Tier Medications:

• Dopamine receptor-blocking drugs (neuroleptics)
  • FDA-approved for Tourette syndrome: haloperidol and pimozide 4
  • Pimozide has shown superior efficacy and fewer side effects compared to haloperidol in controlled studies 4
  • Atypical antipsychotics (risperidone, aripiprazole)
    • Beneficial for patients with significant co-existing behavioral issues 6
    • May have more favorable side effect profiles

Special Considerations for Comorbid Conditions

ADHD with Tics

• Alpha-2 agonists (clonidine or guanfacine) can effectively treat both conditions 4, 5
• Stimulants can be used for ADHD in patients with tics, contrary to earlier concerns 6

Anxiety with Tics

• Alpha-2 agonists may help manage both tics and anxiety 5
• For patients with both ADHD and anxiety, guanfacine (Intuniv) at 0.1 mg/kg once daily is recommended due to lower risk of exacerbating anxiety 5

Aggressive Behavior with Tics

• If aggressive outbursts remain problematic despite tic treatment, mood stabilizers (lithium or divalproex sodium) or an alpha-agonist may be added 4
• For severe, persistent aggression, atypical neuroleptics like risperidone (0.5 mg daily) may be considered 4

Important Clinical Considerations

• Tics typically wax and wane in severity over time and are exacerbated by stress, anxiety, and fatigue 6
• Many tics improve or resolve during adolescence or early adulthood 6
• Treatment should be initiated when tics cause psychosocial problems, functional difficulties, classroom disruption, or physical discomfort 6
• Comorbid conditions (ADHD, OCD, anxiety) often cause more impairment than the tics themselves and should be addressed 6
• Monitor for side effects of medications, particularly sedation, weight gain, and extrapyramidal symptoms with neuroleptics

Emerging Treatments

• Internet-based and telehealth approaches to behavioral therapy show promise for improving accessibility 7, 2
• Deep brain stimulation is an emerging therapy for severe, treatment-resistant cases, though further research is needed to optimize electrode placement and determine precise indications 6

By following this treatment algorithm and considering the patient's specific tic characteristics and comorbidities, clinicians can effectively manage tics while minimizing adverse effects and maximizing quality of life.