Treatment Guidelines: Tic Disorders

General Treatment Approach

The presence of tics alone does not necessarily require treatment. The decision to treat should be based on the degree of distress, physical discomfort, or functional impairment caused by the tics.

Treatment may be indicated when tics are causing:

• Significant distress or embarrassment
• Bullying, social avoidance, or difficulty participating in activities
• Interference with school performance or daily functioning
• Pain, physical discomfort, or injury
• Sleep disruption
• Reduced quality of life

The clinician should also determine whether the child’s primary impairment is caused by the tics or by a comorbid condition such as ADHD, OCD, anxiety, mood symptoms, or behavioral dysregulation. Treatment should prioritize the symptoms causing the greatest impairment. Education regarding the natural waxing and waning of tics should be provided to every patient and family.

The goal of treatment is to reduce tic severity and associated impairment. Complete elimination of tics should not generally be presented as the expected outcome.

Mild or Nonimpairing Tics

When tics are mild and are not causing meaningful distress, pain, injury, or functional impairment, specific tic-suppression treatment is generally not necessary.

Management should include:

• Education and reassurance
• Monitoring of tic severity and functional impact
• Guidance for parents not to criticize, punish, or repeatedly call attention to the tics
• School education and accommodations when appropriate
• Assessment and treatment of comorbid conditions

Watchful waiting is appropriate when the tics are not causing significant impairment.

In addition to monitoring, MindWeal DIY guides may be shared when the child or family would like practical strategies for managing the tics or the stress and anxiety that may exacerbate them. These resources are optional supportive tools and do not mean that mild or nonimpairing tics require active treatment.

CBIT and Habit-Reversal Training

Comprehensive Behavioral Intervention for Tics, or CBIT, should be discussed with patients who have clinically impairing tics.

CBIT combines habit-reversal training with functional interventions and relaxation strategies. Habit-reversal training teaches the patient to recognize the tic or premonitory urge and use a competing response. Functional interventions help identify and manage situations that exacerbate the tics. Relaxation strategies may help reduce stress and physiological arousal that contribute to tic exacerbations.

Where access is available, CBIT, including habit-reversal training, should be considered an initial treatment option for patients with debilitating tics.

CBIT/HRT is a reasonable first-line treatment option when:

• The patient is motivated to participate
• The patient prefers a behavioral treatment
• The family is supportive and able to assist with practice
• The patient is developmentally able to recognize the tic or premonitory urge
• The patient can learn and consistently practice competing responses
• A therapist specifically trained in CBIT or tic-focused habit-reversal training is available

CBIT/HRT should be presented as an available treatment option rather than a mandatory prerequisite before medication.

Families should be informed that CBIT/HRT can be beneficial, but real-world effectiveness may be limited by therapist availability, developmental ability, motivation, family participation, time commitment, and adherence to practice outside of sessions. When the patient and family are interested and able to participate, a referral may be placed.

The MindWeal DIY guides should also be shared as a bridge and additional support.

Medication options should still be discussed at the same time.

CBIT/HRT and medication may be initiated concurrently when clinically appropriate. Medication does not need to be delayed until behavioral treatment has been completed or shown to be ineffective.

Medication Discussion

Medication should be discussed whenever tics are causing clinically meaningful distress or impairment.

Discussing medication does not require the family to start medication. The purpose is to ensure that the patient and family understand:

• The available behavioral and medication options
• The expected degree of improvement
• The possibility that symptoms may wax and wane naturally
• Potential adverse effects
• The role of comorbid ADHD, OCD, anxiety, or behavioral symptoms
• Whether combined behavioral and medication treatment may be appropriate

Medication selection should be based on the child’s clinical presentation rather than a single rigid medication sequence.

Tics With Comorbid ADHD

When ADHD and mild-to-moderate tics occur together, an alpha-2 adrenergic agonist should generally be considered because it may improve ADHD symptoms while also providing modest improvement in tics.

The effect of alpha-2 agonists on tics is variable. Their strongest clinical role is generally in children who have both ADHD and tics.

Guanfacine ER

Guanfacine ER is often the preferred initial alpha-2 agonist when:

• ADHD, hyperactivity, or impulsivity is clinically significant
• Daytime tolerability is important
• Once-daily administration is preferred
• Excessive sedation would interfere with school or daytime functioning

Potential benefits may include improvement in:

• Hyperactivity
• Impulsivity
• ADHD symptoms
• Emotional reactivity
• Mild tic symptoms

The family should be informed that the direct tic-suppressing effect of guanfacine ER is generally modest and inconsistent. It is often selected primarily because of its combined ADHD and behavioral benefits.

Clonidine

Clonidine is another reasonable initial alpha-2 agonist and should not always be considered second-line to guanfacine.

Clonidine may be preferred when:

• Sedation may be beneficial
• The child has sleep-onset difficulty
• Evening hyperactivity or behavioral dysregulation is prominent
• Guanfacine has been ineffective or poorly tolerated
• The clinician believes clonidine is better suited to the individual clinical presentation

Clonidine may have somewhat stronger evidence for tic reduction than guanfacine, but it may also cause greater sedation and hypotension.

Primary Moderate-to-Severe or Disabling Tics

When the tics themselves are the primary source of impairment and are moderate to severe, an alpha-2 agonist may not provide sufficient benefit.

A tic-specific medication should be discussed when:

• Tics are significantly impairing
• Tics are painful or physically injurious
• Tics are causing substantial social or academic consequences
• ADHD is absent or is not the primary treatment target
• CBIT/HRT is unavailable, declined, or insufficient
• More substantial tic reduction is needed

It is not necessary to require unsuccessful trials of both guanfacine and clonidine before considering a tic-specific medication.

Aripiprazole

Aripiprazole is generally the preferred tic-specific medication for children and adolescents with moderate-to-severe or disabling tics.

Aripiprazole may be considered:

• When the tics are the primary source of impairment
• When an alpha-2 agonist is unlikely to provide sufficient benefit
• When an alpha-2 agonist has been ineffective or poorly tolerated
• When CBIT/HRT is unavailable, declined, or insufficient
• Concurrently with CBIT/HRT when clinically appropriate
• When significant irritability or behavioral dysregulation is also present

When Aripiprazole Is Ineffective or Poorly Tolerated

There is no single required medication sequence after aripiprazole. The next treatment should be selected according to the child’s symptoms, adverse-effect risks, comorbidities, and family preferences.

Reasonable options include risperidone, topiramate.

Risperidone

Risperidone may be considered when aripiprazole is ineffective, only partially effective, or poorly tolerated.

Risperidone can provide meaningful tic reduction but may carry a greater risk of:

• Weight gain
• Metabolic adverse effects
• Hyperprolactinemia
• Sedation
• Extrapyramidal symptoms
• Parkinsonism

Because of this adverse-effect burden, aripiprazole is generally preferred before risperidone. This is primarily a benefit-risk and tolerability preference rather than evidence that aripiprazole is always more effective.

Topiramate

Topiramate should be considered an alternative treatment branch rather than automatically being placed after both aripiprazole and risperidone.

Topiramate may be considered when:

• The family wishes to avoid an antipsychotic
• Weight gain is a major concern
• Aripiprazole or another initial medication has been ineffective
• Antipsychotic adverse effects are unacceptable
• The clinician determines that the potential benefits outweigh the cognitive risks

Refractory Tics

Older Antipsychotics

Older antipsychotics such as haloperidol, pimozide, and fluphenazine should generally be reserved for severe or refractory cases because of their greater risk of:

• Extrapyramidal symptoms
• Tardive dyskinesia
• Hyperprolactinemia
• Cardiac adverse effects
• Sedation
• Other significant adverse effects

VMAT2 Inhibitors

Tetrabenazine is the VMAT2 inhibitors prescribed for tics. VMAT2 Inhibitors should not routinely be placed before aripiprazole in the pediatric treatment pathway.

Although open-label experience has suggested potential benefit, controlled pediatric studies have not consistently demonstrated efficacy. Additional considerations include:

• Off-label use
• Limited controlled pediatric evidence
• Side-effects
  • Sedation
  • Akathisia
  • Parkinsonism
  • Mood-related adverse effects
  • Risk of suicidality
• Insurance and access barriers
• High cost

Deutetrabenazine and valbenazine are Newer VMAT2 inhibitors which have also proven to be effective in tics.

Focal, Painful, or Injurious Tics

Botulinum toxin injections may be considered for a persistent focal tic involving a specific muscle group.

This may be particularly appropriate for:

• Painful focal motor tics
• Repetitive cervical or neck tics
• Tics causing physical injury
• Severe localized blinking or facial tics
• Selected focal vocal tics
• A repetitive movement likely to cause musculoskeletal or neurological complications

Botulinum toxin should be viewed as a targeted specialist treatment rather than part of the routine oral-medication sequence. MindWeal does not prescribe Botulinum toxin. Referral to a pediatric neurologist, movement-disorder specialist, or tic specialist is recommended if Botulinum toxin prescription is recommended.

Management of Comorbid Conditions

Comorbid conditions should be independently assessed and treated according to the degree of impairment they cause.

ADHD

Treat clinically significant ADHD adequately. Alpha-2 agonists may help both ADHD and tics, but additional ADHD treatment may be required.

OCD

When OCD is clinically significant, provide appropriate OCD-focused treatment, including exposure-based cognitive behavioral therapy and medication when indicated.

Anxiety and Mood Symptoms

Anxiety and mood symptoms should be treated when they are impairing. Treatment should not focus exclusively on tic suppression when another condition is causing greater distress or dysfunction.

Behavioral Dysregulation

When aggression, rage episodes, irritability, or behavioral dysregulation are prominent, medication selection should take these symptoms into account. Aripiprazole may be particularly useful when significant tics and behavioral dysregulation coexist.

Follow-Up and Monitoring

At each follow-up visit:

• Identify the current most bothersome tic or tics
• Assess distress and functional impairment rather than tic frequency alone
• Review pain, injury, sleep disruption, school impact, and social consequences
• Assess ADHD, OCD, anxiety, mood, and behavioral symptoms
• Review treatment adherence
• Review medication benefits and adverse effects
• Consider the natural waxing and waning of tics when interpreting response
• Avoid escalating medication solely because of a brief or situational tic exacerbation
• Periodically reassess whether medication remains necessary

When tics have remained stable or improved for a sustained period, a gradual medication reduction may be considered to determine whether continued pharmacologic treatment is still needed.

Practical Treatment Pathway

Mild and Nonimpairing Tics

Provide education, reassurance, school support when needed, and clinical monitoring.

Impairing Tics

Discuss both CBIT/HRT and medication.

Offer or refer for CBIT/HRT when the patient is motivated, the family is supportive, and behavioral treatment is their choice.

Medication may be initiated concurrently and does not need to be delayed until CBIT/HRT has been completed.

ADHD With Mild-to-Moderate Tics

Consider guanfacine ER or clonidine based on the child’s clinical presentation.

• Guanfacine ER may be preferred for daytime tolerability and once-daily ADHD treatment.
• Clonidine may be preferred when sedation or help with sleep onset would be beneficial.

Primary Moderate-to-Severe or Disabling Tics

Discuss aripiprazole as the preferred tic-specific medication.

It is not necessary to require unsuccessful trials of both guanfacine and clonidine when the tics are the primary and significant source of impairment.

If Aripiprazole Is Ineffective or Poorly Tolerated

Consider:

• Risperidone
• Topiramate

The choice should be based on the patient’s clinical presentation and adverse-effect priorities rather than a fixed sequence.

Severe or Refractory Tics

Older Antipsychotics

No response to Older Antipsychotics 

Referral to a pediatric neurologist for further evaluation to rule out other movement disorders

Focal, Painful, or Injurious Tics

Refer for consideration of botulinum toxin treatment.