For many individuals, the primary symptoms requiring pharmacological treatment may be behavioral or emotional, such as hyperactivity, impulsivity or obsessions and compulsions. The majority of patients with TS can manage well without drug therapy.
Pharmacotherapy (Medication) for Tics and Co-Occurring Conditions
Haloperidol, pimozide, and aripiprazole are currently the only U.S. Food and Drug Administration (FDA) approved medications to treat tics. However, because all three medications have the potential to cause many unwanted side effects, most physicians start with “off-label” use (not FDA approved specifically for treatment of tics) of guanfacine or clonidine, both of which are alpha-adrenergic agonist medications that are approved for use in the treatment of high blood pressure. These medications have been found to be moderately effective in reducing tics and to be better tolerated.
Problems with the co-occurring conditions, such as ADHD and OCD, often require medication, which can improve quality of life in patients with TS. It is not unusual that treatment of these conditions can also result in a reduction of tics. ADHD symptoms of inattention, impulsivity, and hyperactivity often cause problems for school-aged children. Stimulant medications, such as methylphenidate, can be effective in children who have TS and ADHD. Other non-stimulant medications, such as guanfacine, clonidine, and atomoxetine, may also be beneficial. The selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, sertraline, and fluvoxamine, are effective in youth and adults with anxiety/ OCD. Side effects are generally tolerable. If medication is recommended, make sure the clinician answers all questions about the benefits and risks.
When to Consider Medication Therapy for TS
Medication therapy for TS should be considered if symptoms are functionally disabling and not remediable through non-drug interventions. While a variety of therapeutic agents are now available to treat TS symptoms, each medication should be chosen on the basis of specific target symptoms and potential side effects.
For example, in one patient, tic-suppression may be the important goal, while treatment of obsessive-compulsive features may take precedence in another. Dosages should be titrated slowly in order to achieve the lowest satisfactory dosage. The maximum dosage utilized depends on achieving a “tolerable” suppression of symptoms. “Tolerable” is determined by the nature of the symptoms (for example, coprolalia is usually less tolerable than eye tics) and the ability of an individual to exercise voluntary modulation of his/her vocalizations and motor tics.
Some children may have relatively few tics in school but a great many at home, thus allowing less overall use of medication. In our view, home is a haven where a child can have some relief from holding symptoms in check. It is vital that the patient and the family understand the ever changing nature of TS, so that medications can be adjusted in a rational fashion, increasing when the symptoms upsurge and decreasing during periods of relative remission. It is essential for effective dosage adjustment that “target symptoms” are monitored at all times.
For example, if an individual is treated with so much medication that all movements are suppressed, it can never be known when tics, which tend to wax and wane in severity during the course of the illness, decrease spontaneously. In the long run, our goal is to use as little medication as possible (i.e., “less is best”).
Currently there are a variety of medications available for the treatment of tics and the non-tic symptoms. There is no single medication that is helpful to all individuals with tics or Tourette Syndrome.
For individuals with mild to moderate tics, specific medications effective for tic reduction include clonidine or guanfacine. For individuals with moderate to severe tics, the newer atypical neuroleptics such as risperidone or older traditional neuroleptics such as haloperidol may be indicated.
The decision to use medication should take into account a variety of factors in addition to tic severity such as the child’s age, medical history and past history of response to medication. Typically one medication can be used over several months or longer until the tics have abated.
Medications that target the non-tic symptoms, such as anti-obsessionals (selective serotonin reuptake inhibitors, or SSRIs), or medications for ADHD, such as methylphenidate, dextroamphetamine, or atomoxetine may be indicated. These medications may or may not have direct effects on the tics, in addition t the effects on the behavioral or emotional symptoms.