Recommendation 9: Antipsychotic Treatment for Tics

When the benefits outweigh the risks, antipsychotics may be prescribed for tics at the lowest effective dose. Patients should be counseled on the potential adverse hormonal, extrapyramidal, and metabolic effects to inform decision-making. Clinicians should monitor patients taking antipsychotics for these adverse effects, and if discontinuing, gradually taper dosage over weeks to months to prevent withdrawal dyskinesias.

Recommendation 10: Botulinum Toxin Injections for Tics

When the benefits outweigh the risks, injections with onabotulinumtoxinA botulinum toxin may be prescribed to adults and adolescents with bothersome, localized, simple motor tics and aggressive or severely disabling vocal tics. Patients should be counseled that all effects are temporary, and the injections may cause hypophonia and weakness.

Recommendation 11: Topiramate for the Treatment of Tics

When the benefits outweigh the risks, topiramate can be prescribed, once patients have been counseled on the common adverse effects, which include cognitive and language problems, weight loss, somnolence, and increased risk for kidney stones.

Recommendation 12: Cannabis-based Medications

Some patients with Tourette syndrome self-medicate with cannabis. In places where legislation allows, clinicians should direct self-medicating patients and patients with treatment-resistant and relevant tics to medically supervised cannabis treatments at the lowest effective dose. When prescribing cannabis-based medications, physicians should periodically re-evaluate the need for ongoing treatment. Patients should be advised that the medication impairs driving ability and clinicians should periodically reevaluate the need for continuing treatment. Cannabis-based medications should not be prescribed to children or adolescents, both due to a lack of evidence regarding efficacy and to associations with potentially harmful affective and cognitive outcomes in adulthood. Likewise, women who are pregnant or breastfeeding, and patients with psychosis should not take cannabis-based medications.

Recommendation 13: Deep Brain Stimulation (DBS)

Patients with severe, treatment-resistant Tourette syndrome may benefit from DBS, although treatment availability can be limited and there is limited clinical trial evidence available for analysis and interpretation. To determine if the benefits of DBS will outweigh the risks, clinicians must perform a multidisciplinary evaluation (psychiatrist or neurologist, neurosurgeon, and neuropsychologist). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Tourette syndrome diagnosis must be confirmed and secondary and functional tic-like movements excluded. Clinicians must confirm that behavioral therapy and multiple pharmacological treatments have been attempted or are contraindicated. Preoperative and postoperative screening for psychiatric disorders must be performed by mental health professionals. A mental health professional must screen patients preoperatively and continue to follow-up postoperatively for psychiatric disorders.  Clinicians may consider DBS for patients with severe and self-injurious tics like severe cervical tics that can result in spinal injury.

The lead guideline author states, “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. 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.”

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Pringsheim T, Okun MS, Muller-Vahl K, et al. Practice guideline recommendations summary: treatment of tics in people with Tourette syndrome and chronic tic disorders [published online May 6, 2019]. Neurology doi:10.1212/WNL.0000000000007466

This article originally appeared on Neurology Advisor