Current Management of Tics and Tourette Syndrome: Behavioral, Pharmacologic, and Surgical Treatments

Abstract

Tourette syndrome is a heterogeneous neurobehavioral disorder manifested by childhood-onset motor and phonic tics, often accompanied by a variety of behavioral comorbidities, including attention deficit and obsessive compulsive disorder. Treatment must be tailored to the needs and goals of the individual patients and their families. All patients should receive education on the condition and, if possible, engage behavioral therapy targeted towards tics and/or comorbidities. Pharmacological therapies, such as alpha agonists, topiramate, and vesicular monoamine transport type 2 inhibitors, are generally used as first-line therapies in patients with troublesome tics that are not controlled by behavioral therapy or when the latter is not available or accessible. Botulinum toxin injections can be used in patients with bothersome focal tics. Second-line therapy includes antipsychotics, such as fluphenazine, aripiprazole, risperidone, and ziprasidone. These medications are generally efficacious but carry the risk of metabolic syndrome, tardive dyskinesia, and other side effects. Much more research is needed before novel therapies such as cannabis-derived products or transcranial magnetic stimulation can be recommended. There is promise in ongoing clinical trials with D1 receptor antagonist ecopipam and other experimental therapeutics. Patients with tics that are refractory to conventional treatments may be candidates for deep brain stimulation, but further studies are needed to determine the optimal target selection. Key Words Tourette syndrome (TS) . Tics . Deep brain stimulation (DBS) . Vesicular monoamine transport inhibitor (VMAT2) . Comprehensive behavioral therapy in tics (CBIT)

Refractory Gilles de la Tourette Syndrome—Many Pieces That Define the Puzzle

“…Typical first-line treatment for GTS includes wellestablished behavioral interventions and pharmacotherapy (5). In those cases where these standard treatments are unsuccessful, a number of experimental approaches such as transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), or cannabis-based medicine (CBM) could be implemented (5)(6)(7)(8). Further details of the treatment approach in those cases are discussed in the following sections of the manuscript.…”

Tourette Syndrome and Driving

“…30 It is likely that properly selected and applied individualized comprehensive behavioral intervention for tics (CBIT) and habit reversal training (HRT), coupled with pharmacologic treatment, botulinum toxin and even deep brain stimulation (DBS) enables patients with TS to control their tics for safe driving. 32 Further studies are needed to clarify whether treatment provides functional improvement in patients with driving impairment.…”

Pilot Study to Evaluate Pimavanserin for the Treatment of Motor and Behavioral Symptoms of Tourette Syndrome

“…13 Multiple pharmacological therapies are routinely used in management TS, though no currently available pharmacological therapy has received a level of evidence ranking higher than grade "B" by the American Academy of Neurology for management if tics. 3 Several of these medications modulate serotonin in addition to the principally targeted neurotransmitter, dopamine. The atypical antipsychotics of risperidone, olanzapine, and ziprasidone have both D2 receptor and serotonin antagonist properties.…”

“…These findings warrant further study by a larger, placebo-controlled, trial.Tourette syndrome (TS) is a neurodevelopmental disorder characterized by multiple motor and phonic tics that frequently cooccur with a variety of behavioral and psychiatric problems including obsessive-compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD). [1][2][3] Over the years the results of numerous drug trials, neurophysiological studies, imaging analyses, and examination of human samples (eg, blood, urine, cerebrospinal fluid, brain tissue) have led to several hypotheses regarding the neurochemical abnormalities in TS. 4 The most widely accepted theory suggests dopaminergic dysfunction, however, imbalances in serotonergic, GABAergic, noradrenergic, glutamatergic, and cholinergic systems have been also implicated.…”