As discussed in the previous post, not all individuals with tics need medical treatment. When tics cause pain, interfere with daily activities, disrupt the classroom, or affect social functioning, treatment should be considered. Several treatment options are available. This post will briefly explore some of the treatment options.
TYPES OF TREATMENTS FOR TICS
Medical research supports both behavioral and medicine treatments for tics that are severe and interfere with daily functioning or impair quality of life.1
All patients should be educated about tics and their potential comorbidities (see previous posts). Specific behavioral treatments can also be helpful. The behavioral treatment that appears to have the strongest effect in research studies is called Comprehensive Behavioral Intervention for Tics (or CBIT). CBIT combines training to reduce levels of emotional stress and habit-reversal training. Habit-reversal training teaches patients to become aware of tics before they occur and to suppress them. A previous post discussed that prior to a tic, most patients recognize an urge to perform the tic (called a premonitory urge). Also mentioned in a previous post, tics – by definition – are suppressible. That is, patients can prevent a tic from happening, usually by focusing their attention on something else. CBIT can help patients to suppress tics consistently so that they no longer cause pain or affect normal daily activities. Unfortunately, CBIT might not be available in some areas, and it might not be covered by all medical insurance plans.
There are several categories of drugs used to treat tics. All medicines have potential side effects which is why medicine treatment should be considered only when the tics are severe enough to cause pain or to disrupt or impair daily function. Your healthcare provider will counsel you about the medicine options that are most appropriate, as some medicines have more severe side effects than others. Always discuss treatment goals with the prescribing clinician: an appropriately dosed medicine should improve tic frequency and intensity, but it is rare that medicines lead to disappearance of all tics. A list of commonly used medicines is provided below.1
- Clonidine, guanfacine (alpha-2 agonists)
- Risperidone, ziprasidone, aripiprazole (atypical neuroleptics)
- Haloperidol, pimozide, fluphenazine (typical neuroleptics)
Other treatment options are available or are currently being studied.
Transcranial magnetic stimulation (TMS) uses a magnetic field to create cortical electrical activity (see TMS posts on our blog). Several studies of TMS have been conducted for tic treatment2 but more are needed to better understand the full benefits of this treatment option. At WBMA we have been successful at improving complex tics, both motor and vocal, through TMS without any significant side-effects.
Botulinum toxin (Botox) injection can be helpful when tics cause injury or pain.3 For example, tics that cause rapid or intense movements of the neck can produce a whiplash-type injury. Botox injection into the affected neck muscles can decrease the risk of injury.
Deep-brain stimulation (DBS) is a neurosurgical procedure reserved for selected patients with severe tics that do not respond to medical therapy.4 The procedure can lead to substantial tic improvements, but it is rare to have tics so severe that surgery is required.
¹Matthew E. Hirschtritt, Marisela E. Dy, Kelly G. Yang, Jeremiah M. Scharf. Child Neurology: Diagnosis and treatment of Tourette’s syndrome. Neurology. 2016; 87: e65–e67.
²Grados M, Huselid R, Duque-Serrano L. Transcranial Magnetic Stimulation in Tourette’s Syndrome: A Historical Perspective, Its Current Use and the Influence of Comorbidities in Treatment Response. Brain Sci. 2018; 8: 129.
³Marras C, Andrews D, Sime E, Lang AE. Botulinum toxin for simple motor tics: a randomized, double-blind, controlled clinical trial. Neurology. 2001;56:605-610.
4Coulombe MA, Elkaim LM, Alotaibi NM, Gorman DA, Weil AG, Fallah A, Kalia SK, Lipsman N, Lozano AM, Ibrahim GM. Deep brain stimulation for Gilles de la Tourette’s syndrome in children and youth: a meta-analysis with individual participant data. J Neurosurg Pediatr. 2018;23:236-246.