What medications can be used to treat or control motor tics?

Medications for Motor Tics

For motor tics in Tourette syndrome, risperidone or tiapride should be used as first-line pharmacological treatment, with aripiprazole and pimozide reserved as second-line options. 1

First-Line Pharmacological Options

Atypical Antipsychotics (Preferred)

• Risperidone has the strongest evidence among atypical antipsychotics and should be the preferred first-line agent 1
• Tiapride offers the largest clinical experience in Europe with a notably low rate of adverse reactions, making it an excellent alternative first-line choice 1
• Both agents work through dopamine antagonism, which is the primary mechanism for tic suppression 2

Dosing Considerations

• Start with low doses and titrate gradually to minimize side effects 3
• Risperidone: Initial dose 0.25 mg daily at bedtime, maximum 2-3 mg daily in divided doses 3
• Monitor for extrapyramidal symptoms, which may occur at doses ≥2 mg daily 3

Second-Line Pharmacological Options

When First-Line Agents Fail or Are Not Tolerated

• Aripiprazole shows promising efficacy with a low risk of adverse reactions, though data remain somewhat limited 1
• Pimozide has the best evidence among typical antipsychotics and is FDA-approved specifically for Tourette syndrome 4, 1
• Pimozide should be reserved for patients who have failed standard treatment and whose development/daily function is severely compromised 4

Other Atypical Antipsychotics

• Olanzapine: Initial dose 2.5 mg daily at bedtime, maximum 10 mg daily; generally well tolerated 3
• Quetiapine: Initial dose 12.5 mg twice daily, maximum 200 mg twice daily; more sedating with risk of transient orthostasis 3

Alpha-2 Adrenergic Agonists

Special Role in Comorbid ADHD

• Clonidine is particularly beneficial when ADHD coexists with tics (present in 50-75% of cases) 2
• Alpha agonists can address both tic symptoms and ADHD symptoms simultaneously 2, 5
• Guanfacine is another alpha agonist option with demonstrated efficacy 5

Critical Safety Considerations

Cardiac Monitoring

• Pimozide carries significant QT prolongation risk (mean 13 ms) and requires baseline ECG and ongoing cardiac monitoring 3, 4
• Avoid coadministration with other QT-prolonging medications 3
• Thioridazine has the highest QT prolongation risk (25-30 ms) and carries an FDA black box warning 3

Neurological Side Effects

• Acute dystonia (involuntary motor spasms) typically occurs after first few doses or dosage increases 3
• Tardive dyskinesia occurs in 5% of young patients per year, more common with typical antipsychotics 3
• Atypical antipsychotics have diminished risk of extrapyramidal symptoms compared to typical agents 3
• Akathisia (subjective restlessness) generally occurs within first few days of treatment 3

Metabolic Concerns

• Monitor for weight gain, hyperglycemia, and metabolic syndrome with atypical antipsychotics 3

Treatment Algorithm for Comorbid Conditions

When ADHD Coexists (50-75% of cases)

• Consider atomoxetine, stimulants, or clonidine for ADHD symptoms 1
• Methylphenidate is preferred over amphetamine-based medications (like Adderall), as amphetamines may worsen tic severity 6, 2
• For severe tics with ADHD: combine stimulants with risperidone 1

When OCD/Anxiety/Depression Coexist (30-60% of cases)

• For mild-moderate tics with obsessive-compulsive symptoms: sulpiride monotherapy 1
• For severe cases: combine risperidone with a selective serotonin reuptake inhibitor (SSRI) 1

Common Pitfalls to Avoid

• Do not use typical antipsychotics as first-line due to higher risk of irreversible tardive dyskinesia (50% risk after 2 years continuous use in elderly) 3
• Avoid benztropine or trihexyphenidyl for managing extrapyramidal symptoms in this population 3
• Do not prescribe amphetamine-based stimulants when treating comorbid ADHD, as they worsen tics more than methylphenidate 6, 2
• Intramuscular dosing is preferred over intravenous for parenteral antipsychotic administration due to cardiac safety concerns 3

Treatment-Refractory Cases

Deep Brain Stimulation (DBS)

• Reserved only for severe, treatment-refractory cases with significant functional impairment 7, 2
• Should only be considered after failure of standard pharmacological and behavioral therapies 7
• Approximately 97% of patients in published studies showed improvement 7
• Typically reserved for patients above 20 years of age 2
• Common targets include centromedian-parafascicular thalamus and globus pallidus interna 3

When Pharmacological Treatment Is Indicated

• Not all tics require treatment - only when they interfere with development, daily function, or quality of life 4, 2
• Behavioral techniques (habit reversal training, exposure and response prevention) should be considered as first-line approaches before medications 2
• Medication is reserved for tics that are severely compromising, not merely annoying or cosmetically troublesome 4