Authors: Veit Roessner; Heike Eichele; Jeremy S. Stern; Liselotte Skov; Renata Rizzo; Nanette Mol Debes; Péter Nagy; Andrea E. Cavanna; Cristiano Termine; Christos Ganos; Alexander Münchau; Natalia Szejko; Danielle Cath; Kirsten R. Müller-Vahl; Cara Verdellen; Andreas Hartmann; Aribert Rothenberger; Pieter J. Hoekstra; Kerstin J. Plessen · Research
What Are the Best Medications for Treating Tics in Tourette Syndrome?
An updated review of medication options for treating tics in Tourette syndrome, including recommendations on first-line treatments and management of side effects.
Source: Roessner, V., Eichele, H., Stern, J. S., Skov, L., Rizzo, R., Debes, N. M., ... & Plessen, K. J. (2022). European clinical guidelines for Tourette syndrome and other tic disorders—version 2.0. Part III: pharmacological treatment. European Child & Adolescent Psychiatry, 31(3), 425-441.
What you need to know
- Behavioral therapy is recommended as first-line treatment for tics, but medications are often needed when tics significantly impair quality of life
- Aripiprazole is now considered the first-choice medication for tics in both children and adults due to its effectiveness and favorable side effect profile
- Other recommended medications include tiapride, risperidone, and clonidine/guanfacine (especially for patients with co-existing ADHD)
- Treatment should be individualized based on tic severity, co-existing conditions, and patient/family preferences
- Careful monitoring for side effects like weight gain and movement disorders is essential when using antipsychotic medications
Overview of pharmacological treatment for tics
Tourette syndrome is a neurodevelopmental disorder characterized by multiple motor and vocal tics. While behavioral therapies are recommended as the first-line treatment, many patients require medication to adequately control their tics, especially when tics significantly impair quality of life or cause physical discomfort.
This article summarizes updated European clinical guidelines on the pharmacological treatment of tics in Tourette syndrome, based on a review of recent evidence and expert consensus. The guidelines aim to provide clinicians with practical recommendations on medication selection, dosing, and management of side effects.
First-line medication options
Based on the current evidence and expert opinion, the following medications are recommended as first-line pharmacological treatments for tics:
Aripiprazole
Aripiprazole is now considered the medication of first choice for treating tics in both children and adults. It is an atypical antipsychotic that works as a partial agonist at dopamine receptors. Multiple clinical trials have demonstrated its effectiveness in reducing tics, with a more favorable side effect profile compared to other antipsychotics.
The main advantages of aripiprazole include:
- Good efficacy in reducing tics (comparable to other antipsychotics)
- Lower risk of weight gain and metabolic side effects
- Less sedation and cognitive dulling
- Possibly beneficial effects on co-existing conditions like anxiety and depression
Recommended starting dose is 2.5 mg/day, which can be gradually increased to an effective dose, typically 5-15 mg/day.
Tiapride
Tiapride is a selective dopamine D2 receptor antagonist that is commonly used in some European countries, particularly for children. It has shown efficacy for tic reduction in clinical trials, with a relatively favorable side effect profile. The main side effects include sedation and weight gain, but these are generally milder compared to other antipsychotics.
Typical dosing starts at 50-100 mg/day and can be increased up to 300-400 mg/day as needed.
Risperidone
Risperidone is an atypical antipsychotic with good evidence for tic reduction. It may be especially helpful for patients with co-existing disruptive behavior or irritability. However, it has a higher risk of side effects like weight gain and metabolic changes compared to aripiprazole.
Usual starting dose is 0.25-0.5 mg/day, which can be slowly titrated up to an effective dose, typically 1-3 mg/day.
Clonidine/Guanfacine
These alpha-2 adrenergic agonists are recommended particularly for patients with co-existing ADHD. They can help reduce both tics and ADHD symptoms. Side effects may include sedation and lowered blood pressure.
Typical dosing:
- Clonidine: Start with 0.025-0.05 mg/day, increase gradually up to 0.1-0.3 mg/day
- Guanfacine: Start with 0.5-1 mg/day, increase up to 1-4 mg/day
Other medication options
For patients who do not respond adequately to or cannot tolerate first-line agents, other medication options include:
- Pimozide: A typical antipsychotic that can be effective but has higher risk of side effects
- Haloperidol: Another typical antipsychotic, effective but with significant side effect burden
- Topiramate: An anticonvulsant that may help reduce tics in some patients
- Botulinum toxin injections: Can be used for severe, localized motor or vocal tics
- Cannabis-based medicines: Limited evidence, but may be considered in treatment-resistant adult patients
Individualizing treatment
The choice of medication should be individualized for each patient based on factors like:
- Severity and nature of tics
- Presence of co-existing conditions (e.g. ADHD, OCD)
- Patient age
- Prior response to medications
- Side effect profile and tolerability
- Patient/family preferences
For example, alpha-2 agonists may be preferred in a child with both tics and ADHD, while aripiprazole may be a good first choice for an adolescent with severe motor tics and mild OCD symptoms.
Managing side effects
Careful monitoring for side effects is essential, particularly when using antipsychotic medications. Key points include:
- Baseline and follow-up monitoring of weight, metabolic parameters, and prolactin levels
- Assessment for extrapyramidal side effects like akathisia and tardive dyskinesia
- ECG monitoring, especially with medications that can prolong QT interval
- Gradual dose titration and using the lowest effective dose to minimize side effects
- Consider switching medications if side effects are intolerable or dangerous
Treatment of co-existing conditions
Many patients with Tourette syndrome have co-existing psychiatric conditions that may require separate or integrated treatment approaches:
ADHD
- Alpha-2 agonists (clonidine, guanfacine) can treat both tics and ADHD symptoms
- Stimulants are generally safe and effective for ADHD in patients with tics, despite old concerns about exacerbating tics
- Atomoxetine is another option that may help both ADHD and tics
OCD
- Cognitive-behavioral therapy is first-line treatment
- SSRIs can be added if needed, with no clear differences in efficacy between different SSRIs
- For treatment-resistant cases, augmentation with antipsychotics may be considered
Anxiety/Depression
- SSRIs may help mood symptoms in addition to OCD
- Some evidence that aripiprazole may have positive effects on anxiety and depression
Conclusions
- Pharmacological treatment remains an important option for many patients with Tourette syndrome, especially those with moderate-severe tics impacting quality of life
- Aripiprazole is now considered first-line medication treatment for tics in both children and adults
- Other recommended options include tiapride, risperidone, and alpha-2 agonists
- Treatment should be individualized based on tic severity, co-existing conditions, side effect profiles, and patient preferences
- Careful monitoring and management of potential side effects is essential
- More research is still needed on long-term outcomes, treatment of co-existing conditions, and management of treatment-resistant cases