Gourt Home::Gourt :: Treatment of Tourette syndrome
Treatment of Tourette syndrome does not have the goal of elimination of symptoms, rather the management of symptoms so that individuals can achieve optimum functioning. Tourette syndrome (also Tourette's syndrome or TS) is an inherited neurological disorder with onset in childhood, characterized by the presence of motor and phonic tics. Tourette syndrome occurs along a spectrum of tic disorders, which includes transient tics and chronic tics. Not all persons with Tourette syndrome require treatment, and there is no one treatment that works universally for all individuals.
Tourette syndrome patients may exhibit symptoms of other conditions along with their motor and phonic tics. Associated conditions include attention-deficit hyperactivity disorder (ADD or ADHD), obsessive-compulsive disorder (OCD), learning disabilities and sleep disorders.National Institutes of Health (NIH). Tourette Syndrome Fact Sheet Accessed 23 Mar 2005. Disruptive behaviors, overall functioning, and cognitive function in patients with co-occurring Tourette's syndrome and ADHD may be accounted for by the comorbid ADHD, highlighting the importance of identifying and treating co-occurring conditions when they are present.Sukhodolsky DG, Scahill L, Zhang H, et al. Disruptive behavior in children with Tourette's syndrome: association with ADHD comorbidity, tic severity, and functional impairment. J Am Acad Child Adolesc Psychiatry. 2003 Jan;42(1):98-105. PMID 12500082Hoekstra PJ, Steenhuis MP, Troost PW, et al. Relative contribution of attention-deficit hyperactivity disorder, obsessive-compulsive disorder, and tic severity to social and behavioral problems in tic disorders. J Dev Behav Pediatr. 2004 Aug;25(4):272-9. PMID 15308928Carter AS, O'Donnell DA, Schultz RT, et al. Social and emotional adjustment in children affected with Gilles de la Tourette's syndrome: associations with ADHD and family functioning. Attention Deficit Hyperactivity Disorder. J Child Psychol Psychiatry. 2000 Feb;41(2):215-23. PMID 10750547Spencer T, Biederman J, Harding M, et al. Disentangling the overlap between Tourette's disorder and ADHD. J Child Psychol Psychiatry. 1998 Oct;39(7):1037-44. PMID 9804036 Co-occurring OCD can also be a source of impairment, necessitating treatment. Not all persons with tics will also have co-occurring conditions, but when comorbid disorders are present, they often take treatment priority.
Treatment priority
Treatment of Tourette syndrome can be divided into treatment of tics, and treatment of co-occurring conditions, which, when present, are often a larger source of impairment than the tics themselves.
There is no cure for Tourette's and no medication which works universally for all individuals without significant adverse effects. Knowledge and understanding are the best treatments available for tics. Management of the symptoms of Tourette's may include pharmacologic, behavioral and psychological therapies. While pharmacological interention is reserved for more severe symptoms, treatment with other modalities may help avoid or ameliorate depression or social isolation, and improve supportive family functioning. Educating the patient, family, and surrounding community (school, church, friends, etc.) is a key part of treatment.
The majority of people with TS require no medication, but medication is available to help when symptoms interfere with functioning. Because children with tics often present to physicians when their tics are at their highest severity, and because of the waxing and waning nature of tics, it is recommended that medication not be started immediately or changed often. Frequently, the tics subside with understanding of the condition and a supportive environment. When medication is necessary, pharmaceutical intervention should be targeted at the most impairing symptoms, taking into account co-occurring conditions such as ADHD or OCD, which when present, may warrant treatment even when tics are mild. Zinner SH. Tourette disorder. Pediatr Rev. 2000;21(11):372-383. PMID 11077021
The classes of medications with the most proven efficacy in treating tics — typical and atypical neuroleptics — can have long-term and short-term adverse effects. Bagheri MM, Kerbeshian J, Burd L. Recognition and management of Tourette's syndrome and tic disorders. Am Fam Physician. 1999; 59:2263-2274. The antihypertensive agents, clonidine (Catapres®) and guanfacine (Tenex®), are also used to treat tics. Stimulants and other medications may be useful in treating ADHD when it co-occurs with tic disorders. Drugs from several other classes of medications can be used as alternatives when stimulant trials fail. Clomipramine (Anafranil®), a tricyclic antidepressant, and SSRIs, a class of antidepressants including fluoxetine, sertraline, and fluvoxamine, may be prescribed when a TS patient also has symptoms of Obsessive-compulsive disorder.
Cognitive Behavioral Therapy (CBT) is a useful treatment when OCD is present, and there is increasing evidence supporting the use of habit reversal in the treatment of tics. Relaxation techniques, such as exercise, yoga or meditation, may also be useful in relieving stress that may aggravate tics.
Treatment of tics
There are no medications specifically designed to target tics, although some antipsychotics (e.g.; pimozide) have been FDA-approved for treating Tourette's disorder. Medications which are used as primary treatment in other conditions are used with some success in treating tics. Neuroleptic medications (antipsychotics), such as haloperidol (brand name Haldol®) or pimozide (brand name Orap®), have historically been and continue to be the medications with the most proven efficacy in controlling tics. These medications work by blocking dopamine receptors. However, these drugs are associated with a high adverse effects profile. The traditional antipsychotic drugs are associated with tardive dyskinesia when used long-term, and parkinsonism, dystonia, dyskinesia, and akathisia when used short-term. Additional side effects can be school phobia, depression, weight gain, and cognitive blunting. Another traditional antipsychotic used in treating Tourette's is fluphenazine (brand name Prolixin®), although the empirical support for its use is less than that of haloperidol and pimozide.
Newer neuroleptics, the atypical neuroleptics, are an alternative to the traditional medications used for treating tics. These medications have more selective dopamine blocking effects, or block serotonin with some blocking of dopamine. The medications in this class used to treat tics include risperidone (brand name Risperdal®), olanzapine (brand name Zyprexa®), ziprasidone (brand name Zeldox®), quetiapine (brand name Seroquel®), clozapine (brand name Clozaril®), tiapride, and sulpiride. They seem to have lower risks of neurological side effects (such as tardive dyskinesia) when used short-term, but longer trials are needed to confirm this. Some of the side effects associated with these medications are insomnia, weight gain, and school phobia. Abnormalities in metabolism, cardiac conduction times, and increased risk of diabetes are concerns with these medications. There is good empirical support for the use of risperidone, and less support for the others.
The α2-adrenergic receptor agonists (antihypertensive agents) show some efficacy in reducing tics, as well as other comorbid features of some people with Tourette's. Originally developed to treat high blood pressure, these medications could be a safer alternative to neuroleptic medications for the people with TS that respond to them. This class of medication is often the first tried for tics, as the antihypertensives have a lower side effect profile than some of the medications which more proven efficacy. The evidence for their safety and efficacy is not as strong as the evidence for some of the standard and atypical neuroleptics, but there is fair supportive evidence for their use, nonetheless.Leckman JF, Hardin MT, Riddle MA, et al. Clonidine treatment of Gilles de la Tourette's syndrome. Arch Gen Psychiatry. 1991 Apr;48(4):324-8. PMID 2009034 This class of medication takes about six weeks to begin to work on tics, so sustained trials are warranted. Because of the blood pressure effects, antihypertensive agents should not be discontinued suddenly. Clonidine (brand name Catapres®) works on tics for about half of people with TS. Leckman JF, Cohen DJ, Detlor J, et al. Clonidine in the treatment of Tourette syndrome: a review of data. Adv Neurol. 1982;35:391-401. PMID 6756089Leckman JF, Detlor J, Harcherik DF, et al. Short- and long-term treatment of Tourette's syndrome with clonidine: a clinical perspective. Neurology. 1985 Mar;35(3):343-51. PMID 3883235 Maximal benefit may not be achieved for 4 - 6 months. A small number of patients may worsen on clonidine. Robertson MM. Tourette syndrome, associated conditions and the complexities of treatment. Brain. 2000;123 Pt 3:425-462. PMID 10686169 Guanfacine (brand name Tenex®) is another antihypertensive that is used in treating TS. Side effects can include sedation, dry mouth, fatigue, headaches and dizziness. Sedation can be problematic when treatment is first initiated, but may wear off as the patient adjusts to the medication.
Other medications that can be used to treat tics include pergolide (brand name Permax®), botulinum toxin, and with less empirical support for efficacy, tetrabenazine and baclofen.
Treatment of ADHD in the presence of tic disorders
Referred (clinical) populations of patients with Tourette's have a high rate of comorbid ADHD, so the treatment of ADHD co-occurring with tics is often part of the clinical treatment of Tourette's. The treatment of attention-deficit hyperactivity disorder (ADHD) in the presence of tic disorders has long been a controversial topic. Past medical practice held that stimulants could not be used in the presence of tics, due to concern that their use might exacerbate underlying tic disorders. Freeman, RD. Tourette's Syndrome: minimizing confusion. Accessed 8 February 2006. However, multiple lines of research have shown that stimulants can be cautiously used in the presence of tic disorders.Palumbo D, Spencer T, Lynch J, et al. Emergence of tics in children with ADHD: impact of once-daily OROS methylphenidate therapy. J Child Adolesc Psychopharmacol. 2004 Summer;14(2):185-94. PMID 15319016 Kurlan R. Tourette's syndrome: are stimulants safe? Curr Neurol Neurosci Rep. 2003 Jul;3(4):285-8. PMID 12930697 Law SF, Schachar RJ. Do typical clinical doses of methylphenidate cause tics in children treated for attention-deficit hyperactivity disorder? J Am Acad Child Adolesc Psychiatry. 1999 Aug;38(8):944-51. PMID 10434485 Nolan EE, Gadow KD, Sprafkin J. Stimulant medication withdrawal during long-term therapy in children with comorbid attention-deficit hyperactivity disorder and chronic multiple tic disorder. Pediatrics. 1999 Apr;103 (4 Pt 1):730-7. PMID 10103294 Several studies have shown that stimulants do not exacerbate tics any more than placebo does, and suggest that stimulants may even reduce tic severity.Tourette's Syndrome Study Group. Treatment of ADHD in children with tics: a randomized controlled trial. Neurology. 2002 Feb 26;58(4):527-36. PMID 11865128 Controversy remains, and the PDR continues to carry a warning that stimulants should not be used in the presence of tic disorders, so physicians may be reluctant to use them. Others are comfortable using them and even advocate for a stimulant trial when ADHD co-occurs with tics, because the symptoms of ADHD can be more impairing than tics.
The stimulants are the first line of treatment for ADHD, with proven efficacy, but they do fail in up to 20% of cases, even in patients without tic disorders. Current prescribed stimulant medications include: methylphenidate (Ritalin®, Metadate®, Concerta®), dextroamphetamine (Dexedrine®), and mixed amphetamine salts (Adderall®). Other medications can be used when stimulants are not an option. These include the alpha-2 agonists (clonidine and guanfacine), tricyclic antidepressants (desipramine and nortriptyline), and newer antidepressants (bupropion, venlafaxine and atomoxetine). There have been case reports of tic exacerbations with bupropion (brand name Wellbutrin®). There is good empirical support for the use of desipramine, bupropion and atomoxetine (brand name Strattera®). Atomoxetine is the only non-controlled Food and Drug Administration (FDA) approved drug for the treatment of ADHD, but is less effective than stimulants for ADHD; is associated with individual cases of liver damage; carries an FDA black box warning regarding suicidal ideation; and controlled studies show increases in heart rate, decreases of body weight, decreased appetite and treatment-emergent nausea.Allen AJ, Kurlan RM, Gilbert DL, et al. Atomoxetine treatment in children and adolescents with ADHD and comorbid tic disorders. Neurology. 2005 Dec 27;65(12):1941-9. PMID 16380617
Experimental treatments
Nicotine showed preliminary promise in case reports, but these effects were not reproduced in well-controlled trials several years later. Swerdlow, NR. Tourette Syndrome: Current Controversies and the Battlefield Landscape. Curr Neurol Neurosci Rep. 2005, 5:329-331. PMID 16131414 Studies of nicotine derivatives (mecamylamine, inversine) also showed that they were not effective as monotherapy for the symptoms of Tourette's.Silver AA, Shytle RD, Sheehan KH, et al. Multicenter, double-blind, placebo-controlled study of mecamylamine monotherapy for Tourette's disorder. J Am Acad Child Adolesc Psychiatry. 2001 Sep;40(9):1103-10. PMID 11556635
Case reports found that marijuana helped reduce tics, but validation of these results requires longer, controlled studies on larger samples.Sandyk R, Awerbuch G. Marijuana and Tourette's syndrome. J Clin Psychopharmacol. 1988 Dec;8(6):444-5. PMID 3235704Muller-Vahl KR, Kolbe H, Dengler R. de la Tourette syndrome. Effect of nicotine, alcohol and marihuana on clinical symptoms Nervenarzt. 1997 Dec;68(12):985-9. German. PMID 9465342 Controlled research on treating Tourette's with a synthetic version of tetrahydrocannabinol, the main psychoactive chemical found in cannabis (brand name Marinol®), showed the patients taking Marinol® had a significant reduction in tic severity without serious adverse effects, and more significant reduction in tic severity was reported with longer treatment.Muller-Vahl KR, Schneider U, Prevedel H, et al. Delta 9-tetrahydrocannabinol (THC) is effective in the treatment of tics in Tourette syndrome: a 6-week randomized trial. J Clin Psychiatry. 2003 Apr;64(4):459-65. PMID 12716250 The researchers reported a trend towards improvement in cognitive functioning in patients taking Marinol, before and after treatment.Muller-Vahl KR, Prevedel H, Theloe K, et al. Treatment of Tourette syndrome with delta-9-tetrahydrocannabinol (delta 9-THC): no influence on neuropsychological performance. Neuropsychopharmacology. 2003 Feb;28(2):384-8. PMID 12589392
Complementary and alternative medicine approaches, such as dietary modification, allergy testing and allergen control, and neurofeedback, have popular appeal, but no role has been proven for any of these in the treatment of Tourette syndrome.Zinner SH. Tourette syndrome—much more than tics. Contemporary Pediatrics. Aug 2004;21(8):22-49. Part 1Part 2 Deep brain stimulation has been used in treating a few patients with severe Tourette's, but is regarded as an experimental and dangerous procedure that is unlikely to become widespread.Tourette Syndrome Association. Statement: Deep Brain Stimulation and Tourette Syndrome Accessed 26 Feb 2005.
See also
Notes
"Treatment of Tourette syndrome"