Tic Management

Aka: Tic Management, Tourette's Syndrome Management

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II. Management: Behavioral

  1. Address comorbid conditions
    1. Obsessive-Compulsive Disorder
    2. Major Depression
    3. Anxiety Disorder
    4. Attention Deficit Hyperactivity Disorder (ADHD)
  2. Modalities
    1. Positive reinforcement
    2. Cognitive Behavioral Therapy
    3. Habit reversal training
    4. Address triggers
  3. Targets: Address the most disabling first
    1. Skill deficiencies
    2. Behavior excesses

III. Management: Medications (General)

  1. Indications: Significant tic interfering with daily function
  2. Goal: Lowest medication dose to adequately improve function
  3. Precautions
    1. Often treatment worse than disease
    2. Start at the lowest dose and advance
    3. Observe for Extrapyramidal Effects of Neuroleptics
  4. Medication Maintenance
    1. Tourette's Syndrome requires treatment for up to 2 years
    2. Try slowly tapering medication when stable for 6 months

IV. Management: Medications for mild to moderate Tic Disorder

  1. Clonidine (Catapres)
    1. Start: 0.05 mg orally at bedtime
    2. Advance to: 0.1 mg orally three times daily
    3. Maximum 0.2 mg orally three times daily
  2. Guanfacine (Tenex)
    1. Start: 0.5 mg orally at bedtime
    2. Advance to: 1 mg orally twice daily
    3. Maximum 1 mg orally three times daily
  3. Topiramate (Topamax)
    1. Start: 25 mg orally at bedtime
    2. Advance to: 100 mg PO daily
    3. Maximum 200 mg PO daily

V. Management: Medications for severe Tic Disorder

  1. Precaution
    1. These agents are Neuroleptics with potential serious adverse effects
    2. Typically prescribed by psychiatry
  2. Pimozide (Orap)
    1. Start: 0.5 mg orally at bedtime
    2. Advance to: 1 mg orally twice daily
    3. Maximum 3 mg orally twice daily
  3. Risperidone (Risperdal)
    1. Start: 0.25 mg orally at bedtime
    2. Advance to: 1 mg orally twice daily
    3. Maximum 2 mg orally twice daily
  4. Olanzapine (Zyprexa)
    1. Start: 1.25 mg orally at bedtime
    2. Advance to: 2.5 mg orally twice daily
    3. Maximum 5 mg orally twice daily
  5. Fluphenazine (Prolixin)
    1. Start: 0.5 mg orally at bedtime
    2. Advance to: 1 mg orally three times daily
    3. Maximum 3 mg orally three times daily

VI. Management: Medications for comorbid psychiatric conditions

  1. Clonazepam (Klonopin) for comorbid Anxiety Disorder
    1. Start: 0.25 mg orally at bedtime
    2. Advance to: 0.5 mg orally three times daily
    3. Maximum 1 mg orally three times daily
  2. Medications for concurrent obsessive compulsive features
    1. Clomipramine (Anafranil)
    2. Fluvoxamine (Luvox)
    3. Fluoxetine (Prozac)

VII. References

  1. Jankovic (2001) N Engl J Med 345:1184-92 [PubMed]
  2. Kenney (2008) Am Fam Physician 77:651-60 [PubMed]
  3. Rampello (2006) J Neurol 253:1-15 [PubMed]
  4. Robertson (2000) Brain 123:425-62 [PubMed]

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