What is the best treatment for a 16-year history of motor tics characterized by repetitive neck turning to the left due to an underlying urge?

Treatment of Chronic Motor Tic with Repetitive Neck Turning

For a 16-year history of motor tics characterized by repetitive neck turning to the left driven by an urge, behavioral interventions (habit reversal training or exposure with response prevention) should be offered first-line, with botulinum toxin injections as a highly effective alternative for this specific focal dystonic tic, particularly given the long duration and potential risk of cervical complications. 1, 2, 3

Diagnostic Confirmation

This presentation is consistent with Tourette syndrome, which requires multiple motor tics and at least one vocal tic persisting for at least 1 year with childhood onset. 1 However, even if full Tourette criteria aren't met, the treatment approach for this disabling focal motor tic remains similar. 1, 2

Critical assessment needed:

• Screen for comorbid ADHD (present in 50-75% of cases) and OCD (present in 30-60% of cases), as these significantly impact treatment selection. 1, 2, 4
• Document the functional impairment and quality of life impact, which justifies more aggressive intervention given the 16-year duration. 1
• Evaluate for any neurological complications from the chronic neck movements, particularly cervical myelopathy, which has been reported with severe repetitive neck tics. 5

Treatment Algorithm

First-Line: Behavioral Therapy

• Habit reversal training and exposure with response prevention are recommended as initial treatment for tics. 1, 2, 4
• These approaches are particularly effective when the patient reports premonitory urges (as in this case), which can be targeted therapeutically. 1, 2

Highly Effective Alternative for This Specific Tic: Botulinum Toxin

Given the focal, dystonic nature of this neck tic and its 16-year duration, botulinum toxin type A injections into the involved cervical muscles represent an exceptionally effective treatment option that may be considered early, even before or alongside behavioral therapy. 3, 6, 7

Evidence supporting botulinum toxin for this presentation:

• In patients with dystonic neck tics, 89% achieved good or moderate improvement with botulinum toxin injections. 6
• Mean duration of benefit is 14.4 weeks (up to 45 weeks), with onset of effect within 3.8 days. 7
• Critically, botulinum toxin markedly reduces or eliminates the premonitory urges that drive the tic behavior—70.6% mean benefit for sensory symptoms. 7
• Long-term efficacy is maintained or even increases with repeated treatments, and permanent remission of the treated tic has been documented in some patients. 6
• The treatment is safe, with only transient complications (neck pain, stiffness, or weakness in some patients). 3, 6, 7

Pharmacological Options if Behavioral/Botulinum Approaches Insufficient

If behavioral therapy and botulinum toxin are inadequate or declined:

1. Alpha-2 adrenergic agonists (clonidine or guanfacine) should be initiated first, especially if comorbid ADHD is present. 1, 2, 4

2. Anti-dopaminergic medications (haloperidol, pimozide, risperidone, aripiprazole) are highly effective for tic suppression when alpha-agonists fail. 1, 2, 4

   • Risperidone: Start 0.25 mg daily at bedtime, maximum 2-3 mg daily; monitor for extrapyramidal symptoms at doses ≥2 mg daily. 1
   • Pimozide: Reserved for severe cases unresponsive to standard treatment; requires cardiac monitoring due to QT prolongation risk; not first-line due to higher risk of tardive dyskinesia. 1, 8
   • Start low and titrate gradually to minimize side effects. 1

Advanced Intervention for Treatment-Refractory Cases

Deep brain stimulation (DBS) may be considered if the patient fails behavioral techniques and at least three medications, has severe functional impairment, stable comorbid conditions, and is generally above 20 years of age. 1, 2, 4 DBS targets the centromedian-parafascicular thalamus or globus pallidus interna and shows substantial improvement in approximately 97% of published cases. 2

Critical Clinical Pitfalls

• Do not dismiss this as a "habit" or psychogenic symptom—this leads to inappropriate interventions and delays proper treatment. 2, 4
• Assess for cervical myelopathy—violent repetitive neck tics can cause compressive myelopathy, paraesthesias, sensory deficits, and gait disturbance, which may require urgent neurosurgical evaluation. 5
• Avoid excessive medical testing—diagnosis is clinical, and unnecessary investigations cause iatrogenic harm. 1, 2
• Consider botulinum toxin early for this focal dystonic neck tic rather than waiting for multiple medication failures, given the strong evidence for efficacy and safety in this specific presentation. 3, 6, 7