Tics

A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization that is experienced as involuntary but can often be temporarily suppressed.[1] Tics typically onset between ages 4–6 years and are preceded by a premonitory urge.[1] Transient tics affect up to 20% of children; persistent tic disorders and Tourette syndrome are less common (0.3–1.5%).[2][3]

Tics are categorized as simple or complex:[1]

- Simple motor tics: eye blinking, facial grimacing, shoulder shrugging, head jerking - Simple vocal tics: throat clearing, sniffing, grunting - Complex motor tics: coordinated movements appearing purposeful (e.g., simultaneous head turn and shoulder shrug), echopraxia - Complex vocal tics: repeating words (echolalia, palilalia), or rarely coprolalia

- Provisional tic disorder: motor and/or vocal tics for [4][5] Watchful waiting with psychoeducation is appropriate for mild, non-impairing tics.

Comprehensive Behavioral Intervention for Tics (CBIT) is the only treatment rated with high confidence for efficacy by the AAN and is recommended before pharmacotherapy.[6][5] CBIT includes habit reversal training (awareness of premonitory urge + competing response), relaxation techniques, and functional interventions. It reduces tic severity by 26–31% and treatment gains are maintained for ≥6 months in children aged ≥9 years.[6][5] Efficacy appears comparable to pharmacotherapy.[6]

- First-line: Alpha-2 agonists — guanfacine and clonidine have moderate evidence and a favorable side-effect profile (sedation, hypotension); preferred as initial medication in children. Particularly useful when comorbid ADHD is present.[8][4][9][6] - Second-line: Atypical antipsychotics — aripiprazole, risperidone, and tiapride have evidence for tic reduction but carry risks of metabolic syndrome and tardive dyskinesia.[6][9] - Third-line: Typical antipsychotics — haloperidol and pimozide are effective but reserved for refractory cases due to significant adverse effects (extrapyramidal symptoms, QT prolongation).[9]

Comorbidities are common and should be assessed: ADHD (alpha-2 agonists can treat both), OCD (SSRIs or CBT with exposure/response prevention), anxiety, and learning difficulties.[2][6]

1. Diagnostic and Statistical Manual of Mental Disorders. Dilip V. Jeste, Jeffrey A. Lieberman, David Fassler, et al. American Psychiatric Association (2022). 2. Child Neurology: Simple Motor Tics Associated With Thalamic Ganglioglioma. Chen Y, You M, Zhou H. Neurology. 2024;103(12):e210101. doi:10.1212/WNL.0000000000210101. 3. Comprehensive Systematic Review Summary: Treatment of Tics in People With Tourette Syndrome and Chronic Tic Disorders. Pringsheim T, Holler-Managan Y, Okun MS, et al. Neurology. 2019;92(19):907-915. doi:10.1212/WNL.0000000000007467. 4. Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): Clinical Report. Pediatrics. 2025;155(3):e2024070334. doi:10.1542/peds.2024-070334. 5. Practice Guideline Recommendations Summary: Treatment of Tics in People With Tourette Syndrome and Chronic Tic Disorders. Pringsheim T, Okun MS, Müller-Vahl K, et al. Neurology. 2019;92(19):896-906. doi:10.1212/WNL.0000000000007466. 6. Tourette Syndrome: Clinical Features, Pathophysiology, and Treatment. Johnson KA, Worbe Y, Foote KD, et al. The Lancet. Neurology. 2023;22(2):147-158. doi:10.1016/S1474-4422(22)00303-9. 7. Practice Guideline Recommendations Summary: Treatment of Tics in People With Tourette Syndrome and Chronic Tic Disorders. Pringsheim T, Okun MS, Müller-Vahl K, et al. Neurology. 2019;92(19):896-906. doi:10.1212/WNL.0000000000007466. 8. Practitioner Review: Treatments for Tourette Syndrome in Children and Young People - A Systematic Review. Whittington C, Pennant M, Kendall T, et al. Journal of Child Psychology and Psychiatry, and Allied Disciplines. 2016;57(9):988-1004. doi:10.1111/jcpp.12556. 9. Child Neurology: Diagnosis and Treatment of Tourette Syndrome. Hirschtritt ME, Dy ME, Yang KG, Scharf JM. Neurology. 2016;87(7):e65-7. doi:10.1212/WNL.0000000000002977.