Managing tics in Tourette Syndrome and chronic tic disorders: AAN Guidelines

• Clinicians must evaluate functional impairment related to tics from the perspective of the patient and, if applicable, the caregiver (Level A).


• Clinicians should inform patients and caregivers that watchful waiting is an acceptable approach in people who do not experience functional impairment from their tics (Level B).


• Clinicians may prescribe CBIT as an initial treatment option relative to watchful waiting, for people with tics who do not experience functional impairment if they are motivated to attempt treatment (Level C).


• Physicians prescribing medications for tics must periodically re-evaluate the need for ongoing medical treatment (Level A).


• Clinicians should refer people with TS to resources for psychoeducation for teachers and peers, such as the Tourette Association of America (Level B).


• Clinicians should ensure an assessment for comorbid ADHD is performed in people with tics (Level B).


• Clinicians should evaluate the burden of ADHDsymptoms in people with tics (Level B).


• In people with tics and functionally impairing ADHD, clinicians should ensure appropriate ADHD treatment is provided (Level B).


• Clinicians should ensure an assessment for comorbid OCD is performed in people with tics (Level B).


• In people with tics and OCD, clinicians should ensure appropriate OCD treatment is provided (Level B).


• Clinicians must ensure appropriate screening for anxiety, mood, and disruptive behavior disorders is performed in people with tics (Level A).


• Clinicians must inquire about suicidal thoughts and suicide attempts in people with TS and refer to appropriate resources if present (Level A).


• Clinicians may measure tic severity using a valid scale to assess treatment effects (Level C).


• Clinicians must counsel patients that treatments for tics infrequently result in complete cessation of tics (Level A).


• For people with tics who have access to CBIT, clinicians should prescribe CBIT as an initial treatment option relative to other psychosocial/behavioral interventions (Level B).


• For people with tics who have access to CBIT, clinicians should offer CBIT as an initial treatment option relative to medication (Level B).


• Clinicians may prescribe CBIT delivered over teleconference or secure voice over Internet protocol delivery systems if face-to-face options are unavailable in a patient care center. If CBIT is unavailable, other behavioral interventions for tics may be acceptable, such as exposure and response prevention (Level C).


• with tics and comorbid ADHD that α2 adrenergic agonists may provide benefit for both conditions (Level B).


• Physicians should prescribe α2 adrenergic agonists for the treatment of tics when the benefits of treatment outweigh the risks (Level B).


• Physicians must counsel patients regarding common side effects of α2 adrenergic agonists, including sedation (Level A).


• Physicians must monitor heart rate and blood pressure in patients with tics treated with α2 adrenergic agonists (Level A).


• Physicians prescribing guanfacine extended release must monitor the QTc interval in patients with a history of cardiac conditions, patients taking other QT-prolonging agents, or patients with a family history of long QT syndrome (Level A).


• Physicians discontinuing α2 adrenergic agonists must gradually taper them to avoid rebound hypertension (Level A).


• Physicians may prescribe antipsychotics for the treatment of tics when the benefits of treatment outweigh the risks (Level C).


• Physicians must counsel patients on the relative propensity of antipsychotics for extrapyramidal, hormonal, and metabolic adverse effects to inform decision-making on which antipsychotic should be prescribed (Level A).


• Physicians prescribing antipsychotics for tics must prescribe the lowest effective dose to decrease the risk of adverse effects (Level A).


• Physicians prescribing antipsychotics for tics should monitor for drug-induced movement disorders and for metabolic and hormonal adverse effects of antipsychotics, using evidence-based monitoring protocols (Level B).


• Physicians prescribing antipsychotics for tics must perform electrocardiography and measure the QT_cinterval before and after starting pimozide or ziprasidone, or if antipsychotics are coadministered with other drugs that can prolong the QT interval (Level A).


• When attempting to discontinue antipsychotics for tics, physicians should gradually taper medications over weeks to months to avoid withdrawal dyskinesias (Level B).


• Physicians may prescribe botulinum toxin injections for the treatment of adolescents and adults with localized and bothersome simple motor tics when the benefits of treatment outweigh the risks (Level C).


• Physicians may prescribe botulinum toxin injections for the treatment of older adolescents and adults with severely disabling or aggressive vocal tics when the benefits of treatment outweigh the risks (Level C).


• Physicians must counsel individuals with tics that botulinum toxin injections may cause weakness and hypophonia, and that all effects are temporary (Level A).


• Physicians should prescribe topiramate for the treatment of tics when the benefits of treatment outweigh the risks (Level B).


• Physicians must counsel patients regarding common adverse effects of topiramate, including cognitive and language problems, somnolence, weight loss, and an increased risk of renal stones (Level A).


• Due to the risks associated with cannabis use and widespread self-medication with cannabis for tics, where regional legislation and resources allow, physicians must offer to direct patients to appropriate medical supervision when cannabis is used as self-medication for tics (Level A). Appropriate medical supervision would entail education and monitoring for efficacy and adverse effects.


• Where regional legislation allows, physicians may consider treatment with cannabis-based medication in otherwise treatment-resistant adults with clinically relevant tics (Level C).


• Where regional legislation allows, physicians may consider treatment with cannabis-based medication in adults with TS who already use cannabis efficiently as a self-medication in order to better control and improve quality of treatment (Level C).


• Where regional legislation allows, physicians prescribing cannabis-based medication must prescribe the lowest effective dose to decrease the risk of adverse effects (Level A).


• Physicians prescribing cannabis-based medication must inform patients that medication may impair driving ability (Level A).


• Physicians prescribing cannabis-based medication to patients with TS must periodically reevaluate the need for ongoing treatment (Level A).


• Physicians must use a multidisciplinary evaluation (psychiatrist or neurologist, neurosurgeon, and neuropsychologist) to establish when the benefits of treatment outweigh the risks of prescribing DBS for medication-resistant motor and phonic tics (Level A).


• Physicians should confirm the DSM-5 diagnosis of TS and exclude secondary and functional tic-like movements when considering DBS for medication-resistant tics (Level B).


• A mental health professional must screen patients preoperatively and follow patients postoperatively for psychiatric disorders that may impede the long-term success of the therapy (Level A).


• Physicians must confirm that multiple classes of medication (antipsychotics, dopamine depleters, α2 agonists) and behavioral therapy have been administered (or are contraindicated) before prescribing DBS for tics (Level A).


• Physicians may consider DBS for severe, self-injurious tics, such as severe cervical tics that result in spinal injury (Level C).

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