Management

Seek expert advice.

Tourette's syndrome (TS) is a lifelong condition and treatment is aimed at reducing tic severity and frequency (1)

Treatment options for the management of tics include (1):

• behavioural interventions
• the aim is for patients to identify premonitory urges and modify the response to their occurrence, so that tic expression is delayed and eventually abolished.
• habit reversal training
• exposure and response prevention
• drug treatment
• the European Society for the Study of Tourette Syndrome published the following expert consensus on indications for drug treatment
  • subjective discomfort (such as pain or injury)
  • sustained social problems (such as social isolation or bullying)
  • social and emotional problems (such as reactive depressive symptoms)
  • functional interference (such as impairment of academic achievements).
• dopamine 2 (D2) receptor antagonists
  • studies have shown many neuroleptics, including haloperidol, pimozide - to be effective in treating tics
• newer antidopaminergic agents- the atypical antipsychotics
  • aripiprazole and risperidone
• presynaptic dopamine depletion
  • tetrabenazine is effective for treating tics, and although it does not cause tardive dyskinesia - however it may cause depression and parkinsonism
• adrenergic agonists
  • such as clonidine and guanfacine
    • clonidine is sometimes considered the medication of first choice for the treatment tics in young patients because of its low incidence of side effects and because it can also be of benefit in ameliorating comorbid attention deficit and hyperkinetic disorder (ADHD) (2,3)
      
      
• other treatment
• Botulinum toxin injections
  • indicated for the symptomatic treatment of isolated tics (including vocal tics),
• surgery
  • can be considered for severe treatment refractory cases (2)

The respective summary of product characteristics should be consulted before prescribing medication.

Notes:

• myoclonus or tics?
  • simple motor tics could be confused with myoclonus
  • all patients with tics are almost able to suppress them, even if only partially and temporarily, on request
    • this suppression is followed by a rebound phenomenon, which can be easily observed after the period of voluntary restraint. Such voluntary suppression is never observed for myoclonus
    • tics have patterned profile of muscle activation, which promotes more complex movement than myoclonus
      • even simple motor tics are often the combination of several brief muscle contractions which give rise to the so-called mimicking of normal coordinated movement
        • occasionally, the tic is preceded by premonitory sensations, and patients consider the tic as a voluntary way to obtain relief from these focal sensations - myoclonus is never associated with sensory phenomena

Reference:

• (1) Cath DC et al.European clinical guidelines for Tourette syndrome and other tic disorders. Part I: assessment. Eur Child Adolesc Psychiatry. 2011;20(4):155-71
• (2) Cavanna AE, Seri S.Tourette's syndrome. BMJ. 2013;347:4964
• (3) Dooley JM. Tic disorders in childhood. Semin Pediatr Neurol. 2006 Dec;13(4):231-42.
• (4) Vercueil L. Myoclonus and movement disorders. Neurophysiol Clin. 2006 Sep-Dec;36(5-6):327-31