What is the treatment for tics?

Treatment for Tics

Behavioral therapies are the first-line treatment for tics, including habit reversal training, comprehensive behavioral intervention for tics (CBIT), and exposure and response prevention. 1, 2, 3

Diagnostic Considerations

• Tics are repetitive, patterned, and nonrhythmic movements or vocalizations that are misplaced in context 3
• Proper diagnosis requires fulfillment of DSM criteria and classification as a definitive case according to Diagnostic Confidence Index standards 4, 1
• A comprehensive neurological, neuropsychiatric, and neuropsychological assessment should be performed by a multidisciplinary team 4, 1
• Important to screen for common comorbidities including ADHD (50-75% of cases) and OCD (30-60% of cases) 1

Treatment Algorithm

First-Line: Behavioral Interventions

• Habit reversal training (HRT) - teaches patients to recognize premonitory urges and develop competing responses 1, 2
• Comprehensive Behavioral Intervention for Tics (CBIT) - includes HRT plus relaxation training and functional intervention 2, 5
• Exposure and response prevention (ERP) - involves prolonged exposure to premonitory urges while suppressing tics 1, 2
• These approaches have strong empirical support with high-quality evidence for face-to-face treatment 2, 5
• Video conferencing delivery appears to provide similar benefits to in-person treatment 5

Second-Line: Pharmacological Treatment

If behavioral therapies are insufficient or unavailable:

1. Alpha-2 adrenergic agonists:

   • Clonidine or guanfacine 4, 1
   • Particularly beneficial when ADHD is comorbid 1, 6

2. Anti-dopaminergic medications:

   • Typical antipsychotics: Haloperidol, Pimozide 4, 1
   • Atypical antipsychotics: Risperidone, Aripiprazole 1, 6
   • Consider side effect profiles when selecting specific agents 6

Treatment-Refractory Cases

• For severe, treatment-resistant cases in adults (typically over age 20), deep brain stimulation may be considered 4, 1
• This should only be pursued after failure of at least three medication trials and adequate behavioral therapy 1

Special Considerations

• For patients with comorbid ADHD, stimulant medications can be used but should be monitored carefully as they may occasionally worsen tics 4, 1
• Methylphenidate may be preferable to amphetamine-based medications for ADHD with comorbid tics 1
• For tic cough (previously called habit cough), non-pharmacological approaches like hypnosis or suggestion therapy may be beneficial 4
• Internet-based CBIT programs appear more beneficial than waitlist or psychoeducation alone, though effect sizes may be smaller than in-person treatment 5

Clinical Pitfalls to Avoid

• Misdiagnosing tics as purely habitual or psychogenic behaviors 1
• Excessive medical testing when diagnosis is primarily clinical 1
• Focusing solely on tic management while neglecting treatment of comorbid conditions that often cause more functional impairment 1, 3
• Delaying behavioral interventions in favor of medication-only approaches 2, 7

Behavioral interventions remain the cornerstone of tic treatment with strong evidence supporting their efficacy, while medications provide important options for patients who need additional symptom control.