Tourette Syndrome and Other Tic Disorders Medication

Updated: Jan 12, 2017
  • Author: William C Robertson, Jr, MD; Chief Editor: Amy Kao, MD  more...
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Medication

Medication Summary

The choice of initial treatment depends largely on the following factors:

  • Which symptoms (eg, tics, obsessions, impulsivity) are most problematic
  • The severity of symptoms
  • The patient's sense of urgency for treatment
  • The patient's aversion to risk of likely or unlikely adverse effects

For many patients the most reasonable option is to forgo treatment altogether. Education of patient and family (and teacher or employer) may suffice. If a single dystonic tic predominates, especially in the face, neck, or larynx, botulinum toxin injection is a reasonable first treatment.

If ADHD symptoms predominate, they can be addressed first. Guanfacine or clonidine has the best evidence for also improving tics; stimulants have the best efficacy for ADHD symptoms. Other options are noted in the treatment section above.

If OCD symptoms predominate, they can be addressed first, most likely with a serotonin reuptake inhibitor and/or risperidone.

If severe tics are the presenting symptom, a newer antipsychotic agent may be the best initial treatment. The dose used is substantially lower than the dose used to treat psychosis.

If tics are mild to moderate in severity or if they occur in risk-averse patients, any of the non-antipsychotic treatments described in Treatment can be tried sequentially. Clonidine may be the most widely used, while habit reversal therapy likely has the lowest risk of serious adverse effect. The combination of dopamine antagonists with stimulants is used sometimes, yet it makes little enough sense pharmacologically that other options should be explored thoroughly.

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Antipsychotic Agents

Class Summary

These agents affect dopamine receptors but also affect serotonin receptors involved with frontal lobe functions.

Risperidone (Risperdal)

Risperidone is a mixed dopamine-serotonin antagonist that may produce less sedation than other antipsychotics. Theoretically, risperidone has a lower risk of tardive dyskinesia than haloperidol; it clearly produces fewer acute adverse effects.

Olanzapine (Zyprexa)

Olanzapine is an atypical antipsychotic that produces fewer acute parkinsonian, akathisic, or dystonic adverse effects than haloperidol. In schizophrenia, it has approximately 33%-50% the risk of tardive dyskinesia compared with haloperidol.

Ziprasidone (Geodon)

Ziprasidone is an atypical antipsychotic. In a head-to-head study, this agent caused less weight gain than olanzapine in schizophrenia.

Haloperidol (Haldol)

The anti-tic efficacy of haloperidol has been known for 40 years. It blocks postsynaptic mesolimbic dopaminergic D1 and D2 receptors in the brain. It also decreases hypothalamic and hypophyseal hormones.

Fluphenazine

Fluphenazine is a high-potency typical antipsychotic with pharmacology similar to that of haloperidol. It is proven to diminish tic severity.

Pimozide (Orap)

Pimozide is an atypical neuroleptic approved by the US Food and Drug Administration (FDA) for treatment of tics. It is rarely indicated in current practice, as it offers no substantial advantage over other high-potency neuroleptics (risperidone and olanzapine are better tolerated), has significant drug interactions, and poses a slight but serious risk of cardiac arrhythmia.

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Presynaptic Dopamine-Depleting Agents

Class Summary

These agents suppress tics. They are presynaptic depleting agents that have acute adverse effects similar to neuroleptics but theoretically may avoid the risk of tardive dyskinesia.

Tetrabenazine (Xenazine)

This agent depletes neurotransmitter stores of dopamine, serotonin, and noradrenaline within nerve cells in the brain, thereby altering the transmission of electric signals from the brain that control movement by reversibly inhibiting vesicular monoamine transporter 2 (VMAT2).

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Dopamine Agonists

Class Summary

These agents suppress tics. Dopamine agonists have few adverse effects and modest but proven efficacy.

Pergolide (Permax)

Pergolide was withdrawn from the US market March 29, 2007, because of heart valve damage resulting in cardiac valve regurgitation. It is important not to abruptly stop pergolide. Health care professionals should assess patients' need for dopamine agonist (DA) therapy and consider alternative treatment. If continued treatment with a DA is needed, another DA should be substituted for pergolide.

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Alpha2-Adrenergic Agonists

Class Summary

These agents are used for tic suppression or for treatment of ADHD.

Clonidine (Catapres)

Clonidine is less effective than neuroleptics in suppressing tics and less effective than stimulants at treating ADHD symptoms. However, it has modest adverse effects and benefits some patients.

Guanfacine (Tenex, Intuniv)

Guanfacine has been proven to benefit ADHD and, to a lesser extent, tic severity in children with chronic tics and ADHD.

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Skeletal Muscle Relaxants

Class Summary

These agents may suppress the severity of tics.

Baclofen (Lioresal, Gablofen)

Although slightly effective in children with TS, baclofen's primary effect may not be on tics but on other symptoms; adverse effects are modest.

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Benzodiazepines

Class Summary

By binding to specific receptor sites, these agents appear to potentiate the effects of gamma amino-butyric acid (GABA) and facilitate inhibitory GABA neurotransmission and other inhibitory transmitters.

Clonazepam (Klonopin)

Clonazepam reduces tics in some patients, although blinded controlled studies are lacking. Its half-life is longer than 30 hours, but its clinical effect wanes more rapidly.

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Neuromuscular Blockers

Class Summary

These agents suppress tics and possibly premonitory sensations.

OnabotulinumtoxinA (BOTOX)

This agent inhibits release of acetylcholine at neuromuscular junction; it is injected directly into muscle. It is most useful for dystonic tics (eg, sustained eye closure) or only 1 or 2 especially problematic tics (eg, repeatedly flinging head to 1 side causing neck pain and broken glasses). Tics and tic urges may improve; effect can be seen in absence of gross weakness. Successful outcomes require substantial specialized experience in the treating physician.

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