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What is the first line treatment for tics?

Tics are sudden, rapid, recurrent, nonrhythmic motor movements or vocalizations. Tics can be simple or complex, and examples include eye blinking, shoulder shrugging, sniffing, throat clearing, and grunting. Tics often start in childhood and follow a waxing and waning course. Tourette syndrome is diagnosed when an individual has multiple motor and vocal tics that have been present for at least 1 year.

What causes tics?

The exact cause of tics is unknown, but it is thought to involve abnormalities in certain brain regions including the basal ganglia and frontal cortex. Factors that are believed to contribute to tics include:

  • Genetics – tics often run in families.
  • Brain chemistry – tics may be related to abnormal levels of neurotransmitters like dopamine and serotonin.
  • Autoimmune mechanisms – antibodies directed at brain tissue may trigger tics in some cases.
  • PANDAS – tics that suddenly appear following a streptococcal infection.

How are tics diagnosed?

Diagnosis of tics and Tourette syndrome involves:

  • Medical history – the doctor asks about onset and course of tics.
  • Physical exam – the doctor observes tics during the visit.
  • PANDAS testing – strep testing and titers if PANDAS is suspected.
  • Referral to neurologist – may order MRI or EEG to rule out other causes.

There are no blood tests or diagnostic criteria for Tourette syndrome. The diagnosis is made clinically based on the history of waxing and waning motor and vocal tics.

What is the first line treatment for tics?

The first line treatment for tics is behavioral intervention. This involves:

  • Habit reversal training – the patient learns to be aware of sensations before tic onset and does a competing behavior such as clenching fists or tensing muscles.
  • Comprehensive behavioral intervention – combines habit reversal with functional intervention, relaxation training, and coping strategies.

Studies show that behavioral therapy can significantly improve tics in many patients. It should be tried first before medications are considered.

Medications used for tics

If behavioral therapy is insufficient, medications may be used as an adjunctive treatment for tics. Commonly used medications include:

Medication Mechanism
Clonidine Alpha-2 adrenoreceptor agonist
Guanfacine Alpha-2 adrenoreceptor agonist
Antipsychotics (risperidone, haloperidol) Dopamine receptor antagonist

These medications help suppress tics through their effects on dopamine and noradrenaline in the brain. They can cause side effects like sedation and weight gain. Patients must be monitored closely on these medications.

Are antibiotics used for tics?

Antibiotics are not routinely used for tics or Tourette syndrome. However, they may be warranted in certain situations:

  • Acute symptom onset – Sudden onset of tics following a streptococcal infection may indicate PANDAS. A course of antibiotics like penicillin or amoxicillin can be used in this situation.
  • Exacerbations with infections – Some patients experience worsening tics with recurrent strep infections. Prophylactic antibiotics may help prevent flare-ups.

The efficacy of long-term antibiotic therapy for Tourette syndrome remains controversial. It should be carefully considered given potential side effects.

How effective is behavioral therapy for tics?

Studies have found behavioral interventions to be quite effective for reducing tics:

  • A meta-analysis in 2021 looked at 14 clinical trials using habit reversal training. Tic severity declined by an average of 49% with behavioral therapy.
  • A randomized trial in 2016 compared 8 weeks of habit reversal training to supportive therapy in children with Tourette syndrome. The behavioral therapy group had significantly greater improvement in tic scores.
  • A trial in Germany in 2013 found that adding a behavioral intervention to medications led to significantly better tic improvement than medication alone.

Based on this evidence, behavioral therapy should be first-line for tics. Gains are often maintained long-term as patients continue to use learned techniques.

Study 1

McGuire JF, Nagpal C, Abbott CW, et al. Efficacy of Psychotherapy for Tics: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2021;78(3):297–305.

What are the side effects of tic medications?

Medications used for tics can cause various side effects including:

Medication Potential Side Effects
Clonidine Dry mouth, sedation, low blood pressure, depression
Guanfacine Headache, fatigue, abdominal pain, low blood pressure
Risperidone Weight gain, high prolactin, sedation, movements disorders
Haloperidol Sedation, akathisia, extrapyramidal symptoms, tardive dyskinesia

Patients on tic medications should be closely monitored with regular follow-up. Dose adjustments or discontinuation may be required if problematic side effects emerge.

What are lifestyle recommendations for tics?

Certain lifestyle measures may help minimize tic severity and impact:

  • Reduce stress – Since stress exacerbates tics, practicing relaxation techniques like yoga, meditation, or deep breathing can help.
  • Get enough sleep – Adequate sleep is important as fatigue makes tics worse.
  • Regular exercise – Aerobic exercise helps reduce tic severity for some patients.
  • Avoid trigger substances – Caffeine, nicotine, and recreational drugs can exacerbate tics.

Keeping up with behavioral therapy exercises, minimizing stress, and leading a healthy lifestyle can help augment the benefits of treatment.

What support is available for families dealing with tics?

Families dealing with Tourette syndrome may benefit from various support resources:

  • Local support groups – Opportunity to connect with other families facing similar challenges.
  • National Tourette Association – Offers camps, conferences, mentorship programs.
  • Behavioral therapy programs – Help parents better reinforce techniques at home.
  • School accommodations – IEP or 504 plan if tics disrupt academics.
  • Individual and family counseling – Helps develop coping mechanisms.

Accessing community support resources, understanding educational rights, and working closely with the treatment team can help improve resilience.


Tics are best treated initially with behavioral interventions like habit reversal training rather than medications. Therapy helps patients learn to self-regulate tics without significant side effects. Accessing support, reducing stress, avoiding trigger substances, and leading a healthy lifestyle can further help manage tics. While tics may wax and wane over time, a multidisciplinary approach focused on behavioral therapy provides patients with the tools to achieve optimal control.