Tics vary in severity from infrequent and barely noticeable to nearly continuous and highly disruptive. Treatment of
tic disorders depends on the severity of the
tics, the distress they cause, and the effects they have on school, work, or daily activities. Many
tics do not interfere with school or everyday life and do not require specific treatment. Comorbid disorders such as
attention deficit hyperactivity disorder, anxiety, and
obsessive-compulsive disorder occur in more than 50% of patients. The associated comorbidity can be more bothersome than the
tics themselves. Treatment should be aimed at the most troubling symptom. Education and reassurance are often sufficient for mild and occasional
tics. For
tics of moderate severity,
clonidine and
guanfacine have a reasonable safety profile. They are considered as first-line medications. With
clonidine, start with 0.05 mg at bedtime. Increase as needed and as tolerated by 0.05 mg every 4 to 7 days to a maximum dosage of 0.3 to 0.4 mg/day divided three or four times a day. With
guanfacine, start with 0.5 mg at bedtime. The dosage may be increased as needed and as tolerated by 0.5 mg every week to a maximum dosage of 3 to 4 mg/day, divided twice a day. There are emerging data that behavioral
therapy is effective for treatment of
tics in some individuals.
Dopamine receptor blockers are the most potent medications for treating severe
tics. The efficacy appears to be proportionate to the affinity for
dopamine D2 receptors. Thus, standard
antipsychotic medications such as
haloperidol,
pimozide, or
fluphenazine are the most potent. However, these medications commonly cause bothersome side effects. Therefore, we recommend use of atypical
neuroleptics before standard
neuroleptics in most patients.
Risperidone is usually the first choice and may have efficacy for behavior problems that often accompany
tics. Start with 0.01 mg/kg/dose once a day; dosage may be increased by 0.02 mg/kg/day at weekly intervals, up to 0.06 mg/kg/dose once a day.
Ziprasidone and
olanzapine are reasonable alternatives.