New AAN guideline for treating tourette syndrome and other chronic tic disorders

May 09, 2019

For people living with Tourette syndrome and other chronic tic disorders, there are effective treatments that may help improve symptoms, according to a new guideline by the American Academy of Neurology (AAN) published in the May 7, 2019, online issue of Neurology®, the medical journal of the AAN. The guideline is endorsed by the Child Neurology Society and the European Academy of Neurology.

An accurate diagnosis, ongoing medical assessment of the severity of tics, as well as treatments that include holistic care, behavioral strategies, and medications based on the latest scientific evidence could mean a better chance of managing tics over time.

Tics are repetitive movements and vocalizations prompted by an irresistible urge to produce them. They are the defining feature of chronic tic disorders, including Tourette syndrome which is a neurodevelopmental disorder that begins in childhood.

“Tourette syndrome and other chronic tic disorders can be of great concern to the person diagnosed and their family, so it is important that doctors let those affected know that tics may improve with time,” said guideline lead author Tamara Pringsheim MD MSc of the University of Calgary in Alberta, Canada, and a Fellow of the American Academy of Neurology. “Treatments can help decrease tic frequency and severity, but they rarely eliminate all tics. It is important that people are informed of all the available treatment options, which include education, behavioral therapies, medication, or watchful waiting.”

For the guideline, authors reviewed all available evidence. They recommend that when a person has tics that are not causing physical impairment, pain, emotional distress, or social embarrassment, that watching and waiting is an acceptable management strategy when also combined with providing education that helps the person better understand and cope with the disorder. Treatment must be individualized and based on a collaborative decision among the patient, their caregivers and their doctor. The guideline also recommends that doctors tell children with tics and their caregivers that there is a good chance that their symptoms will improve in late adolescence.

If symptoms affect a person’s daily life, the guideline recommends that doctors first consider prescribing a treatment called Comprehensive Behavioral Intervention for Tics (CBIT). CBIT combines relaxation training, habit-reversal training, and behavioral therapy to help reduce tic symptoms. The guideline states that CBIT is effective in both children and adults and has no major side effects.

It is common for people with tic disorders to have neurodevelopmental and psychiatric conditions. The guideline recommends that people with tics are evaluated for attention deficit hyperactivity disorder, obsessive-compulsive disorder, and mood and anxiety disorders since treatment for these disorders may also be needed. In some cases, one medication can help lessen symptoms of both a tic disorder and another coexisting disorder. Medications called alpha-2 adrenergic agonists can improve symptoms of both tic disorders and attention-deficit/hyperactivity disorder.

When there is more benefit than risk, doctors may prescribe antipsychotic medications for tics, however doctors must discuss and provide monitoring for the many side effects that can occur with these drugs. If a person wants to stop taking these medications, it is recommended that doctors slowly lower the dose to prevent abnormal movements that can occur if the medication is stopped too quickly.

Additional treatments outlined in the guideline include botulinum toxin, which is a medicine given by injection into the muscles that produce tics. The guideline states that doctors should counsel their older teenage and adult patients about this treatment, based on limited evidence.

The guideline recommends that adults with severe Tourette syndrome who are resistant to medical and behavioral therapy may benefit from deep brain stimulation, but that they must first be screened by a mental health professional and continue to be monitored throughout deep brain stimulation treatment.

Finally, the guideline mentions that some adults with Tourette syndrome treat their tics on their own by using cannabis, or marijuana. Because there are risks of using cannabis, the guideline recommends that a person’s doctor directs them to a doctor who can supervise their use of cannabis for treatment of tics, and only in states where cannabis is legal.

Source: News Release
American Academy of Neurology
May 6, 2019