Medication for Tourette Syndrome
This material if for information purposes only. If you have specific questions about medication for Tourette Syndrome (TS), you should discuss them with a specialist.
For some people, the variety of symptoms of TS can lead to problems in everyday life. For them medication may be an effective way to reduce the symptoms and improve their quality of life. However, side effects are not uncommon with these drugs and effectiveness varies from person to person meaning that they are not beneficial for everyone who tries them.
Finding the right medication
Clinicians need to work closely with patients and their families when deciding about drug treatments, especially to balance potential risks and benefits. The decisions that need to be made include:
- whether or not to treat;
- which symptoms to treat - tics or other aspects like attention deficit hyperactivity disorder or obsessive compulsive disorder; and,
- whether a combination of medication is necessary to treat the different symptoms.
Finding the right treatment for TS is often an individual process due to the wide range and severity of symptoms and the occurrence of associated conditions such as ADHD, OCD and depression. Also, tics naturally ‘wax and wane’, meaning that periodically they get better and worse over time. So, sometimes therapies appear to be working well, but this may be coincidental with a period in which tics are naturally less severe.
General rules for using medication to treat TS and related symptoms
Medication does not treat the underlying cause of TS but can treat some of the symptoms. There are rules that clinicians use in deciding on drug therapies. Firstly, is to find out which symptoms are the most problematic in order to treat them accordingly. Sometimes there can be disagreement about which symptoms are the main problem (i.e. a child with TS may think the tics are the biggest problem, whilst the parents may think that behaviour in school is). This requires sensitive discussion and agreement before treatment is started.
Treatments in TS usually follow the ‘start low, go slow’ rule (i.e. start at a low dose and increase the dose slowly). This means that side-effects, if they do occur, can be more easily recognised and it is easier to tell the difference between effects of the treatment and underlying fluctuations in the TS symptoms. It is also advisable to make just one change at a time. If too many changes are made quickly and the TS improves or gets worse, it is hard to know which change was responsible.
Stopping treatments suddenly is usually not a good idea, however sometimes, this has to be done (e.g. if a person gets an acute reaction to a treatment) but this should only be done in consultation with your doctor.
It can be useful to keep a diary of how you feel on each dose of medication or medication type. This means that you can look back and work out which treatment or combination worked best for you with the fewest side-effects.
When you go and see your doctor about TS, always bring your medication or prescription with you so that the doctor knows what you are taking and can give you the best advice.
Types of Medication
There are many drug treatments available for the symptoms of TS but they will only form part of the overall treatment plan and some people will not need drug treatments at all. It is important to keep talking to your specialist as this will help them to advise you about which treatments to use. None of the options are addictive and no single drug has been discovered that is clearly superior in all patients. Common types of medications used to treat TS are discussed below:
Drugs used to treat tics
These drugs work by blocking dopamine receptors in the brain and include drugs regarded as the most useful in reducing tics. Dopamine has been strongly linked with TS. Neuroleptics are primarily marketed for treating psychotic conditions like schizophrenia, but there is no clinical link between psychosis and TS - dopamine appears to be important for both conditions.
Examples of medications in this group include Aripiprazole, Sulpiride, Risperidone, Pimozide, Olanzapine, Quetiapine and the older drug Haloperidol.
Unfortunately, these types of drugs can also block other important signalling pathways in the brain such as cholinergic, serotonergic and alpha-adrenergic transmission. This may lead to unpleasant side effects including sudden stiffness and prolonged muscle contraction (acute dystonia), shaking, restlessness and more commonly drowsiness.
Medicines in this group may affect a person’s emotional state (for instance make them feel sad or tired). Long term treatment with these drugs can very occasionally cause another movement disorder, in addition to tics, called tardive dyskinesia (involuntary repetitive movements). The risk is very small but may occasionally persist after treatment is stopped.
Haloperidol is associated with more side effects than modern neuroleptics, so it is seldom used in the UK now, although it was the first drug to successfully treat TS.
Pimozide is widely used in Europe for the treatment of tics and studies show this drug is an effective treatment. It causes less side effects than Haloperiodol but it has been associated with problems in heart rhythms and therefore patients should have a heart tracing (ECG) before use, shortly after starting treatment and at intervals thereafter. Some common drugs (such as antibiotics) can make the effect of Pimozide stronger, so great care needs to be taken when other drugs are prescribed at the same time. You should always make sure that your doctor or pharmacist knows what other medication you are taking
The newer or ‘atypical’ neuroleptics are now more likely to be prescribed. These types of drug are more selective dopamine signalling blockers, however, they are also known to affect serotonin - an important signalling chemical in the brain. This may have advantages but may cause significant side effects. Drugs in this category include Aripiprazole, Risperidone, Olanzapine and Quetiapine.
Aripiprazole has become a commonly used neuroleptic for TS. There are some indications that it is more effective and tolerable than other options and may also improve behavioural symptoms, but the level of evidence for this is still limited. This drug has a unique mechanism of action as it partially stimulates the dopamine D2 receptor as well as having an effect on other receptors in the brain. It has the advantage of being less likely to cause weight gain and other metabolic effects than the other neuroleptics. Side effects from this drug are usually mild to moderate and temporary including insomnia or drowsiness, fatigue, nausea and headaches.
Risperidone has been investigated extensively with many studies reporting positive effects – including a positive effect on other co-morbid conditions associated with TS such as Obsessive Compulsive Behaviour and aggression. Side effects however can include fatigue and somnolence, emotional disturbance, nausea, vomiting, sleep problems and weight gain.
Olanzapine and Quetiapine are similar drugs but have been less used and have little evidence.
There are also several other drugs that can be used to treat TS that do not fall neatly into the categories previously described. Benzamides (for example Sulpiride) are thought to be effective in reducing tics but like the other options side effects can include drowsiness and depression. These drugs could also be described as neuroleptics. Sulpiride was popular in the UK before newer options came along and is still used, usually as a second neuroleptic option.
Tetrabenazine reduces the amount of dopamine signalling by a different mechanism. This drug is also thought to be effective but has been linked to side effects including fatigue, nausea, depression and insomnia.
Other drugs, such as Clonidine, work by stimulating the alpha-2 adrenergic system which inhibits the release of noradrenaline. Clonidine has been used for many years in the treatment of tics and also improves ADHD. Due to this, and it being a way to avoid a neuroleptic, it is frequently used in children. Side effects may include drowsiness, sedation, headaches, depression and dizziness. Clonidine is also used in adults as medication for people with high blood pressure.
This means that people taking Clonidine should have their blood pressure taken before they start and during treatment. It should not be stopped suddenly without a slow reduction because that could cause a severe rise in blood pressure.
Topiramate is an epilepsy drug that has shown to be effective and affects other signalling pathways than dopamine. Cannabinoid-like medications may reduce tic severity, but also have known side effects and are not yet fully evaluated
Drugs used to treat ADHD
There are a number of drugs used to treat ADHD but we do not consider them here. One of the main questions about the treatment of ADHD in people who also have TS is whether or not the treatment for ADHD makes the tics worse? Many doctors have reported that treatment with stimulant medications such as Ritalin (methylphenidate) may have caused tics to worsen, even though attention and concentration has often improved. However, tics can vary considerably over time and so it can be difficult to find out whether a change in treatment (such as adding a stimulant) was responsible for making tics worse or whether it was just a natural change in the severity of the TS which would have happened anyway.
More recent studies and opinion suggest that drugs for ADHD do not generally lead to worsening of tics. Atomoxetine is a relatively new medication in the treatment of ADHD. A large trial showed that it is effective in children with TS and may even improve tics as well as ADHD.
Drugs used to treat OCD
The group of drugs used to treat depression known as SSRIs (Selective Serotonin Reuptake Inhibitors) are also effective for OCD, sometimes requiring higher doses. Cognitive behavioural treatment used in combination with SSRIs may be most effective.
Further Information about medication in TS
Most of this information has been adapted from Eddy et al. 2011 and Roessner et al. 2011 which contains further details on the types of treatments available for TS. The details on this page were last updated in June 2013 by Dr Jeremy Stern, TA Honorary Medical Director and Consultant Neurologist at St George's Hospital, Tooting, London
Please note that the information about medication on the Tourettes Action’s website is for information purposes only. If you have any specific questions about your medication, you should discuss this with your TS specialist before undertaking any changes.