Tourette's syndrome - Treating Tourette's syndrome

There are several treatment options available for people with Tourette's syndrome.

Treatment plan

The first and most important part of treatment for Tourette's syndrome is to ensure that you, your child and, if needed, your child’s teachers, friends and other family members all have good information and knowledge about the condition. This includes:

being able to explain Tourette’s syndrome to others if asked about tics
understanding that tics are not ‘put on’
understanding that tics come and go and that sometimes they may be better than at other times
knowing that having tics does not generally stop you doing anything you want to do
knowing that treatments may help to relieve tics, but are unlikely to make them go away completely
being aware that most people ‘outgrow’ tics by the time they reach adulthood

Next, the treatment plan for tics could involve one or more of the following:

treatments that do not involve taking medication – such as behavioural therapy
medication – the three types of medication that may be prescribed are alpha2-adrenergic agonists, muscle relaxants and dopamine antagonists
surgery – in very rare, severe cases, surgical techniques may be suitable

Non-medical treatments alone, such as behavioural therapy, may be needed if the tics are relatively mild and infrequent.

In cases where a person's tics are more severe and disrupt day-to-day activities, a combination of therapy and medication may be recommended.

Surgery is usually only recommended as a 'treatment of last resort' if the tics are very severe and fail to respond to other treatment.

The doctor in charge of your or your child’s care, usually a neurologist (a brain and nervous system specialist), will recommend what they think is the best treatment option. However, the final decision will be yours.

If your child is old enough to understand fully the implications of their decision, they will be asked to decide what treatment they would prefer.

Behavioural therapy

Behavioural therapy is a widely used non-medical treatment for Tourette’s syndrome. It is a type of psychological treatment that is designed to change the pattern of your or your child’s behaviour.

Habit reversal

Habit reversal is a type of behavioural therapy that has proved successful in treating Tourette’s syndrome. It is based on the following two principles:

people with Tourette’s syndrome are often unaware of their tics
tics are used to relieve uncomfortable feelings, called premonitory sensations, that build up before tics

The first stage is to monitor the pattern and frequency of the tics, and identify any sensations that are triggering them. The next stage is to find an alternative, less noticeable method of relieving the premonitory sensations instead of a tic. This is known as a competing response.

For example, your child may experience an unpleasant sensation in their throat that causes them to grunt. Therefore, the next time your child feels the unpleasant sensation, they are asked to take a series of deep breaths rather than grunting, to try to relieve the sensation.

Habit reversal is often combined with relaxation therapy. Relaxation techniques, such as deep breathing or visualisation (thinking about something pleasant as a distraction), can help prevent feelings of stress and anxiety, which can often make tics worse.

Exposure and response prevention (ERP)

Exposure and response prevention (ERP) involves increasing exposure to the urge to tic in order to suppress the tic response for longer. This works on the theory that you get used to the feeling of needing to tic until the urge, and any related anxiety, decreases in strength.

Medication

Alpha2-adrenergic agonists

Alpha2-adrenergic agonists are usually recommended for treatment of mild to moderate symptoms of Tourette’s syndrome.

This type of medication is thought to stabilise levels of a brain chemical called norepinephrine. This is thought to decrease the risk of the basal ganglia misfiring and triggering tics.

Clonidine is the alpha2-adrenergic agonist that is widely used to treat Tourette’s syndrome.

Common side effects of clonidine include:

drowsiness
headaches
dizziness
fatigue
constipation
diarrhoea
a dry mouth
difficulties sleeping

These side effects are usually mild and should improve when the body gets used to the medication.

Muscle relaxants

Muscle relaxants have been shown to be effective in helping control tics, particularly physical tics.

Baclofen and clonazepam are two muscle relaxants that are sometimes used to treat Tourette’s syndrome. You or your child may feel drowsy and dizzy after taking these.

Adults being treated with muscle relaxants should not drive or use tools or machinery if they feel dizzy or drowsy. You should also avoid drinking alcohol while taking muscle relaxants because it could make you feel very ill.

Dopamine antagonists

Dopamine antagonists are the most effective type of medication for preventing tics. However, they can cause a wide range of side effects, so will only be recommended in cases where the symptoms are particularly severe or fail to respond to other medications.

Dopamine antagonists are given orally (as a tablet) or by injection. They work by blocking the effects of dopamine on the brain. Dopamine is a chemical in the brain thought to be associated with tics.

There are two main types of dopamine antagonists. They are:

first generation dopamine antagonists – that were developed in the 1950s
a newer generation of dopamine antagonists – that were developed in the 1990s

Both the older and newer dopamine antagonists have side effects, although not everyone experiences them, and their severity differs from person to person.

The side effects of the older dopamine antagonists include:

drowsiness
shaking
trembling
muscle twitches
spasms

Side effects of both the older and newer dopamine antagonists include:

weight gain
blurred vision
constipation
a dry mouth

The newer generation of dopamine antagonists are usually recommended because they are less likely to cause side effects. However, they are not suitable or effective for everyone.

Adults with Tourette’s syndrome who are being treated with dopamine antagonists may also experience a loss of libido (decreased sex drive).

If your child has been prescribed a dopamine antagonist, and they are finding the side effects particularly troublesome, you should contact the doctor in charge of their care. There may be an alternative that your child will be able to tolerate better.

Aripiprazole is the newest type of dopamine medicine that seems to be helpful and appears to have fewer side effects. Although there has not yet been a large clinical trial of this medicine for Tourette’s syndrome, it has been used successfully in many people with tics.

An experienced doctor may be able to offer aripiprazole as a treatment option.

Surgery and deep brain stimulation (DBS)

Surgery is usually regarded as a 'treatment of last resort' for people with severe Tourette’s syndrome that has failed to respond to other treatments. It is usually only recommended for adults.

The aim of surgery is to make a small ‘break’ in some of the pathways in the brain that may be responsible for tics. The region of the brain that is usually operated on is called the limbic system, although several different areas have been targeted.

Surgery has largely been replaced with deep brain stimulation (DBS). This is a relatively new technique that, like surgery, has been used to treat very severe cases of Tourette’s syndrome where other treatments have failed.

DBS involves permanently implanting electrodes (small metallic discs) in the parts of the brain that are known to be associated with Tourette’s syndrome.

The electrodes are attached to small generators that are implanted elsewhere in the body. The generators send electronic pulses to the electrodes, which stimulate different parts of the brain. By stimulating certain areas of the brain the symptoms of Tourette’s syndrome can often be controlled.

Initial results of DBS have been encouraging, with some people showing a substantial reduction in their tics that lasted for more than five years. DBS appears to be most effective when combined with behavioural therapy (see above).

However, both limbic system surgery and DBS have only been used on a small number of people with Tourette’s syndrome, and there is not yet sufficient evidence to justify their use as standard treatments for the syndrome.