New guidelines have been published for the treatment of tics in people with Tourette syndrome and chronic tic disorders.

Developed by the American Academy of Neurology the 46 recommendations include counselling on the natural history of tic disorders, psychoeducation for teachers and peers, assessment for comorbid disorders, and periodic reassessment of the need for ongoing therapy.

Key recommendations include:

• Watching and waiting as a management strategy could work for those whose tics are not disrupting everyday life. This should be done under consultation with a doctor who can educate the person to understand and cope with what is going on.
• Treatments must be individualised and based on a collaborative decision by those living with Tourette syndrome, caregivers and doctors.
• Doctors should talk to children and caregivers about how tics could improve with age for some.
• For those whose tics are disruptive, a first treatment option to consider is Comprehensive Behavioural Intervention for Tics. CBIT combines relaxation training, habit-reversal training and behavioural therapy.
• Patients with tics should be evaluated for other commonly coexisting conditions such as attention deficit hyperactivity disorder, obsessive-compulsive disorder and mood and anxiety disorders. For some, one medication can help lessen symptoms for both issues. In some cases, antipsychotic medications for tics are prescribed but if other side effects associated with these drugs are seen, patients must be weaned off under a doctor’s supervision to prevent abnormal movements seen when medications are stopped too quickly.
• Botulinum toxin given by injection into the muscles might be an option for older teenage or adult patients.
• Deep Brain Stimulation is an option for those who are resistant to medical and behavioural therapy, but they must first be screened by a mental health professional and continue to be monitored throughout DBS treatment.
• The guidelines take into account the experiences of adults who have, on their own, treated their Tourette syndrome tics using cannabis. A person who chooses to do this should talk to his or her doctor. If a physician is not authorised to supervise the use of cannabis, the physician should recommend a doctor who is authorised and only in states where cannabis is legal.

Dr Joseph Jankovic, professor of neurology and director of the Parkinson’s Disease Center and Movement Disorders Clinic at Baylor College of Medicine, is one of the authors of the guidelines, published in Neurology.

“If the tics are not interfering with patient’s functioning or social interactions, behavioural therapy, if performed by a trained therapist, can be helpful. However, by the time patients with Tourette syndrome are referred to our movement disorders clinic at Baylor, some form of pharmacologic therapy is often needed,” he said.

“There are many therapeutic options available for the treatment of Tourette, but the most important message from the guidelines is that therapy of Tourette must be individualised.”

Dr Jankovic said drug therapies such as tetrabenazine, deutetrabenazine and valbenazine were not mentioned in the new guidelines, partly because they have not yet been approved by the FDA in Tourette syndrome.