What are the treatment options for a facial tic?

Treatment Options for Facial Tics

For patients with facial tics, a stepwise approach should be implemented starting with behavioral therapy, followed by alpha-2 adrenergic agonists, and progressing to atypical neuroleptics or botulinum toxin injections for more severe cases. 1

First-Line Treatments

• Education and reassurance are often sufficient for mild and occasional tics that do not interfere with daily functioning 1

• Behavioral therapy including habit reversal training and exposure and response prevention has proven efficacy for tic management and should be attempted before pharmacological interventions 1, 2

Pharmacological Options

Alpha-2 Adrenergic Agonists (First-line medications)

• Clonidine: Start with 0.05 mg at bedtime, then increase by 0.05 mg every 4-7 days as needed and tolerated to a maximum of 0.3-0.4 mg/day divided three to four times daily 1

• Guanfacine: Begin with 0.5 mg at bedtime, then increase by 0.5 mg weekly as needed to a maximum of 3-4 mg/day divided twice daily 1

Antipsychotic Medications (For more severe tics)

• Atypical neuroleptics should be used before standard neuroleptics due to better side effect profiles 1

• Risperidone is typically the first choice: Start with 0.01 mg/kg once daily, increase by 0.02 mg/kg weekly up to 0.06 mg/kg once daily 1

• Ziprasidone and olanzapine are reasonable alternatives for patients who don't respond to or cannot tolerate risperidone 1

• Traditional antipsychotics (haloperidol, pimozide, fluphenazine) are most potent but have higher risk of side effects 1

Botulinum Toxin Therapy

• Botulinum toxin injections are highly effective for focal facial tics and can improve both the motor component and premonitory sensations 3, 4

• Treatment should be administered by a specialist experienced in botulinum toxin injections 4

• Injections are typically given directly into the affected muscles causing the tic 4, 3

• Benefits typically last 14.4 weeks on average (range 1.5-45 weeks) 3

• 84% of patients with premonitory sensations experience significant relief of these symptoms (mean benefit 70.6%) 3

• Potential side effects include localized weakness, pain at injection site, and rarely ptosis when treating facial muscles 4, 3

• Retreatment should not be administered more frequently than every three months 4

Advanced Treatment Options

• Deep Brain Stimulation (DBS) may be considered for severe, treatment-refractory cases of Tourette Syndrome with disabling tics 2

• DBS candidates must:

  • Be at least 20 years of age 2
  • Have failed behavioral therapy and at least three medications including alpha-2 agonists and antipsychotics 2
  • Experience tics causing severe functional impairment 2
  • Have stable treatment for any comorbid conditions for at least 6 months 2

Important Considerations

• Comorbidities such as ADHD, anxiety, and OCD occur in >50% of patients with tic disorders and may require separate treatment 1, 2

• Age is an important factor - approximately half of patients with tics experience spontaneous remission by age 18 2

• Quality of life assessment is essential when determining treatment approach, as this should be the primary goal of intervention 2

• Treatment should target the most troublesome symptoms, whether they are the tics themselves or associated comorbidities 1

Treatment Algorithm

1. For mild tics: Education, reassurance, and behavioral therapy
2. For moderate tics: Alpha-2 agonists (clonidine or guanfacine)
3. For severe tics: Atypical antipsychotics (risperidone first) or botulinum toxin for focal tics
4. For treatment-refractory disabling tics: Consider DBS in appropriate candidates