What treatment options are available for chronic neck tics that have persisted for 16 years?

Treatment of Chronic Neck Tics Persisting 16 Years

For a patient with chronic neck tics turning towards the left for 16 years, botulinum toxin injections into the affected cervical muscles represent the most effective and safest treatment option, particularly given the risk of cervical myelopathy from prolonged violent neck movements. 1, 2

Immediate Clinical Assessment Required

Before initiating treatment, you must evaluate for:

• Cervical myelopathy signs: Check for upper and lower extremity weakness, sensory deficits, gait disturbance, bladder/bowel dysfunction, and hyperreflexia 1, 2
• Premonitory sensations: Over 80% of tic patients experience urges or sensory experiences preceding the tic 3
• Core tic features: Suppressibility, distractibility, suggestibility, variability 4
• Comorbid conditions: Obsessive-compulsive disorder, attention deficit hyperactivity disorder, anxiety, depression 3, 5

Critical pitfall: Two case reports document patients with violent neck tics who developed compressive cervical myelopathy and tetraparesis from chronic repetitive neck movements. 1, 2 After 16 years of symptoms, neuroimaging is essential.

Diagnostic Workup

Obtain MRI of the cervical spine without contrast immediately to rule out:

• Cervical spinal stenosis 2
• Retrospondylosis 2
• Cord compression or myelomalacia 1
• Structural abnormalities 2

The 16-year duration places this patient at substantial risk for mechanical spine complications that could cause irreversible neurological damage if left untreated. 1, 2

Treatment Algorithm

First-Line: Botulinum Toxin Injections

Inject botulinum toxin into the posterior cervical muscles (or specific muscles involved in the leftward turning movement). 3, 1, 2

• This approach directly targets the problematic tic without systemic side effects 1, 5
• One case report demonstrated complete resolution of severe cervical tics after 12 months of botulinum toxin treatment combined with neuroleptics 1
• Another patient with cervical myelopathy from neck tics showed gradual improvement with botulinum toxin injections 2
• Botulinum toxin is particularly effective when there are a few disabling motor tics, as in this case 5

Second-Line: Oral Medications (if botulinum toxin insufficient)

If botulinum toxin alone provides inadequate control, add oral medication:

Start with atypical neuroleptics (preferred over typical neuroleptics due to better side effect profile):

• Olanzapine 5-10 mg/day 3
• Risperidone 3
• Aripiprazole 4

Alternative if atypical neuroleptics fail:

• Typical neuroleptics: Pimozide (superior to haloperidol in efficacy and side effects) 4
• Haloperidol 4
• Tiapride 3

Important caveat: Oral medications reduce tic severity but rarely eliminate tics completely. 5 High-potency typical neuroleptics carry risk of serious side effects including extrapyramidal symptoms, tardive dyskinesia, and sedation. 3

Third-Line: Deep Brain Stimulation (for treatment-refractory cases)

Consider DBS referral only if:

• Patient has failed behavioral therapy (habit reversal training, exposure and response prevention) 4
• Failed therapeutic doses of at least three medications including anti-dopaminergics and alpha-2 agonists 4
• Yale Global Tic Severity Scale score indicates severe functional impairment 4
• Stable treatment for comorbid conditions for at least 6 months 4
• Age >20 years (to account for potential spontaneous remission) 4

DBS targets include the thalamus or nucleus accumbens/anterior limb of internal capsule, though this remains investigational. 4

Critical Management Considerations

Do not delay treatment: The 16-year duration of violent neck tics places this patient at high risk for irreversible spinal cord injury. 1, 2 One reported patient developed progressive tetraparesis requiring surgical decompression, with continued neurological deterioration despite surgery. 2

Avoid these common errors:

• Treating with oral medications alone when focal botulinum toxin would be more effective and safer 1, 5
• Failing to obtain cervical spine imaging in a patient with chronic violent neck movements 1, 2
• Using typical neuroleptics as first-line when atypical agents have better tolerability 3

Monitor for:

• Development of new neurological symptoms suggesting myelopathy 1, 2
• Worsening tic severity or frequency 5
• Emergence of psychiatric comorbidities requiring separate treatment 3, 5

Prognosis

While most tic disorders show spontaneous improvement by late adolescence, this patient's 16-year history indicates a chronic course unlikely to remit spontaneously. 6 However, aggressive treatment with botulinum toxin combined with oral medications when needed can achieve substantial symptom control and prevent devastating neurological complications. 1