What is the recommended treatment for a 24-year-old with a 16-year history of motor tics, specifically repetitive neck turning towards the left due to urges, suggestive of Tourette syndrome?

Treatment for Motor Tics with Repetitive Neck Turning in a 24-Year-Old

Start with behavioral therapy as first-line treatment, specifically habit reversal training or comprehensive behavioral intervention for tics (CBIT), before considering pharmacological options. 1, 2

Diagnostic Clarification

This clinical presentation requires clarification of the diagnosis before treatment:

• If only motor tics are present (repetitive neck turning without vocal tics over 16 years), this represents Chronic Motor Tic Disorder, not Tourette syndrome, which requires both multiple motor tics AND at least one vocal tic persisting for at least 1 year 1, 3
• The presence of premonitory urges (the "urges" described) followed by temporary relief after the tic is a core distinguishing feature of tic disorders 3
• The 16-year duration with onset at age 8 fits the chronic pattern typical of tic disorders 1

Critical Safety Consideration

Violent or repetitive neck-turning tics can cause cervical myelopathy and spinal cord compression, which is a medical emergency. 4 Before initiating treatment:

• Perform a thorough neurological examination looking for signs of myelopathy: sensory deficits, weakness in extremities, gait disturbance, bladder dysfunction 4
• If any myelopathic signs are present, obtain urgent cervical spine imaging (MRI) to assess for spinal cord compression 4
• This complication can develop after years of repetitive neck tics and requires immediate intervention 4

Treatment Algorithm

First-Line: Behavioral Therapy

Initiate habit reversal training or CBIT as the primary treatment approach. 1, 2

• These behavioral techniques should be the initial intervention before medications 1, 2
• Success requires a cooperative patient, presence of premonitory urges (which this patient has), and commitment to the therapy 5
• Exposure and response prevention (ERP) is specifically recommended as first-line behavioral therapy 2

Second-Line: Pharmacological Treatment (If Behavioral Therapy Insufficient)

Use a two-tier medication approach starting with alpha-2 adrenergic agonists for milder tics, progressing to antipsychotics for more severe cases. 1, 5

Tier 1: Alpha-2 Adrenergic Agonists

• Clonidine is the recommended first-line medication, particularly beneficial if comorbid ADHD is present 1, 2
• This tier is appropriate for milder tics that require pharmacological intervention 5

Tier 2: Antipsychotics (For More Severe Tics)

Start with low doses and titrate gradually to minimize side effects: 1

• Risperidone: Start 0.25 mg daily at bedtime, maximum 2-3 mg daily in divided doses 1

  • Monitor for extrapyramidal symptoms at doses ≥2 mg daily 1
  • Avoid coadministration with QT-prolonging medications 1

• Pimozide and Fluphenazine are alternative options based on physician experience 5

  • Pimozide requires cardiac monitoring due to significant QT prolongation risk 1

• Aripiprazole is another effective option with advantages in side-effect profile 5, 6

• Atypical antipsychotics (olanzapine, quetiapine) have diminished risk of extrapyramidal symptoms compared to typical agents 1

Critical warning: Typical antipsychotics should NOT be first-line due to higher risk of irreversible tardive dyskinesia 1

Third-Line: Botulinum Toxin for Focal Tics

• For persistent, bothersome focal neck tics, botulinum toxin injections into posterior cervical muscles can be effective 4, 6
• This is particularly relevant for this patient's specific presentation of repetitive neck turning 4

Fourth-Line: Deep Brain Stimulation

At age 24, this patient meets the age criterion for DBS consideration if other treatments fail. 1, 2

DBS candidacy requires: 2

• Failed response to behavioral techniques
• Failed response to at least three medications proven efficacious for tics
• Severe functional impairment due to tics
• Age above 20 years (this patient qualifies)
• Stable and optimized treatment for any comorbid conditions

Essential Comorbidity Screening

Screen for ADHD (present in 50-75% of cases) and OCD (present in 30-60% of cases), as these often cause greater impairment than tics themselves. 1, 3, 5

• Comorbid conditions frequently require treatment before or alongside tic management 5, 7
• If ADHD is present, stimulants can be used safely and typically do not worsen tics 2
• Amphetamine-based medications may worsen tics more than methylphenidate 1

Key Clinical Pitfalls to Avoid

• Do not perform excessive medical testing—diagnosis is primarily clinical and unnecessary testing causes iatrogenic harm 1, 3
• Do not use benztropine or trihexyphenidyl for managing extrapyramidal symptoms in this population 1
• Do not misdiagnose as psychogenic or habit behavior, which leads to inappropriate interventions 1, 3, 2
• Do not overlook the possibility of cervical myelopathy in patients with chronic violent neck tics 4