How do you treat facial tics?

Treatment of Facial Tics

For facial tics, education and reassurance are sufficient for mild cases, while moderate-to-severe tics should be treated first with clonidine or guanfacine, reserving dopamine receptor blockers like risperidone for severe cases that fail first-line therapy. 1

Initial Assessment and Treatment Decision Algorithm

Before initiating pharmacologic therapy, determine tic severity and impact:

• Mild, infrequent tics that do not interfere with school, work, or daily activities require no medication—education and reassurance alone are sufficient. 1
• Moderate severity tics causing some functional impairment warrant first-line pharmacologic treatment with alpha-2 adrenergic agonists. 1, 2
• Severe, disabling tics that significantly impair function require second-line dopamine receptor blockers. 1, 2

Evaluate for comorbid conditions (ADHD, OCD, anxiety, depression) in all patients, as these occur in >50% of cases and may be more troubling than the tics themselves—treat the most bothersome symptom first. 1, 2

First-Line Pharmacologic Treatment: Alpha-2 Adrenergic Agonists

Clonidine is the preferred initial medication for moderate facial tics:

• Start with 0.05 mg at bedtime. 1
• Increase by 0.05 mg every 4–7 days as needed and tolerated. 1
• Maximum dosage: 0.3–0.4 mg/day divided 3–4 times daily. 1

Guanfacine is an alternative first-line option:

• Start with 0.5 mg at bedtime. 1
• Increase by 0.5 mg every week as needed and tolerated. 1
• Maximum dosage: 3–4 mg/day divided twice daily. 1

These agents have a reasonable safety profile and are particularly beneficial when ADHD coexists with tics. 1, 2

Second-Line Treatment: Dopamine Receptor Blockers

When first-line agents fail or tics are severe, dopamine receptor blockers are the most potent medications available. 1 Efficacy is proportionate to dopamine D2 receptor affinity. 1

Atypical antipsychotics are recommended before typical neuroleptics in most patients due to better tolerability:

• Risperidone (first choice among atypical agents):

  • Start with 0.01 mg/kg/dose once daily. 1
  • Increase by 0.02 mg/kg/day at weekly intervals. 1
  • Maximum: 0.06 mg/kg/dose once daily. 1
  • Additional benefit for behavioral problems that often accompany tics. 1

• Aripiprazole is particularly beneficial when significant behavioral issues coexist. 2

• Ziprasidone and olanzapine are reasonable alternatives. 1

Typical neuroleptics (haloperidol, pimozide, fluphenazine) are the most potent but commonly cause bothersome side effects—reserve for refractory cases. 1, 2

Non-Pharmacologic Treatment Options

Comprehensive Behavioral Intervention for Tics (CBIT) has emerging evidence of effectiveness:

• Requires a cooperative patient, presence of premonitory urge, and committed family. 2
• Habit reversal is the major component. 2
• Consider as adjunct or alternative to medication in motivated patients. 1, 2

Specialized Interventions for Refractory Cases

Botulinum toxin injections are effective when there are a few particularly disabling motor tics localized to specific facial muscles. 3, 4

Deep brain stimulation has been reported effective for the most severe cases but remains unproven and should only be considered after all other options have failed. 3

Critical Clinical Pitfalls

• Do not withhold treatment based solely on the expectation that tics will improve with age—functional impairment, psychosocial problems, and physical discomfort are clear indications for intervention. 2
• Avoid typical neuroleptics as first-line therapy due to high risk of bothersome side effects including tardive syndromes. 1, 5
• Screen for secondary causes and ensure proper diagnosis before initiating treatment—not all facial movements are primary tic disorders. 3
• Monotherapy is recommended—avoid polypharmacy when possible. 2