What is Tourette's (Tourette Syndrome)?

From the Guidelines

Tourette's syndrome should be treated with a combination of behavioral therapy and medication, prioritizing alpha-2 adrenergic agonists like clonidine or guanfacine for mild to moderate tics, and antipsychotics like risperidone, aripiprazole, or pimozide for more severe cases, as supported by the most recent and highest quality study 1.

Key Considerations

• The diagnosis of Tourette's syndrome involves ruling out other conditions that may present with similar symptoms, such as habit cough or psychogenic cough, and considering the presence of co-occurring conditions like ADHD, OCD, anxiety, and depression 1.
• Behavioral therapy, including Comprehensive Behavioral Intervention for Tics (CBIT) and habit reversal training, is a crucial component of treatment, teaching patients to recognize premonitory urges and develop competing responses.
• Medication should be individualized, starting with the lowest effective dose to minimize side effects, and considering the potential benefits and risks of different medications, such as the effectiveness of pimozide in controlling tics with fewer side effects compared to haloperidol 1.

Treatment Options

• Alpha-2 adrenergic agonists like clonidine (0.1-0.3 mg daily) or guanfacine (1-4 mg daily) are often tried first, especially in children with mild to moderate tics.
• Antipsychotics such as risperidone (0.5-3 mg daily), aripiprazole (2-15 mg daily), or pimozide (1-4 mg daily) may be used for more severe cases, as they work by blocking dopamine receptors and reducing tic symptoms.
• The use of stimulant medications, such as those used to treat ADHD, may be considered in patients with Tourette's syndrome, but should be approached with caution and careful monitoring, as they may exacerbate tics in some cases, although recent studies suggest that they may not worsen motor tics in Tourette's syndrome 1.

From the Research

Overview of Tourette's Syndrome

• Tourette's Syndrome (TS) is a neurodevelopmental disorder characterized by multiple motor and vocal tics, which can be associated with comorbid conditions such as attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) 2, 3, 4.
• The treatment of TS is multimodal, including both pharmacotherapy and cognitive behavioral treatment, and requires disentanglement of tics and comorbid symptoms 4.

Pharmacological Treatment Options

• The most frequently used drugs for tics are antipsychotics, such as pimozide and haloperidol, and clonidine 3.
• Atypical antipsychotics, such as risperidone and aripiprazole, are often recommended as first-line treatment due to their efficacy and tolerability 2, 4, 5.
• Alpha-adrenoceptor agonists, such as guanfacine and clonidine, have an established evidence base for both efficacy and tolerability, and are usually recommended as initial pharmacotherapy 4, 5.
• Other pharmacological agents, such as selective serotonin reuptake inhibitors (SSRIs) and stimulants, may be useful in patients with comorbid conditions such as OCD and ADHD 3, 6.

Efficacy and Safety of Pharmacological Treatments

• Response rates for pharmacological treatments have been reported to be high, with aripiprazole showing a response rate of 88.6%, clonidine 68.9%, risperidone 62.5%, and guanfacine 19% 5.
• Statistically significant improvements have been reported for all medications compared to placebo in at least one study and for at least one measure of tic severity 5.
• However, most studies have been of poor quality and short duration, and there is limited evidence to determine whether adults respond differently from children 5.

Non-Pharmacological Treatment Options

• Behavioral therapies, such as cognitive behavioral therapy and habit reversal training, may be effective in reducing tic severity and improving quality of life 6.
• Other non-pharmacological therapies, such as hypnotherapy, biofeedback, and acupuncture, may also be beneficial, but the evidence is limited 3, 6.