Update on the Treatment of Tics in Tourette Syndrome and Other Chronic Tic Disorders

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This review presents a critical appraisal of current therapeutic strategies for tics in patients with Tourette syndrome (TS) and other chronic tic disorders. We discuss the most recent evidence to support behavioural/psychosocial, pharmacological and surgical interventions in patients with tics and summarize existing recommendations about treatment selection. We also indicate the main knowledge gaps regarding efficacy, safety and prioritization of interventions and provide a summary of the emerging therapeutic approaches. During the past few years, high-quality randomized controlled trials have documented the efficacy and safety of the Comprehensive Behavioural Intervention for Tics (CBIT), based on the habit reversal training strategy. Preliminary data encourage larger trials of the online, remotely delivered, therapist-supported format of CBIT and exposure response prevention. Antipsychotic medications, with recent evidence supporting in particular the use of aripiprazole, and alpha agonists remain the main pharmacological options, alongside botulinum toxin injections for the treatment of simple motor tics. Emerging pharmacological options include ecopipam, a D1-selective dopamine agonist, and endocannabinoid modulators. Increasing experience with thalamic and pallidal deep brain stimulation is paving the way to the development of closed loop approaches and an anticipation of the age limit for consideration of this surgical treatment in otherwise refractory and disabled patients. Behavioural therapy should be considered as a first line of active intervention for tics, given its demonstrated efficacy and high tolerability. Pharmacological options (antipsychotics, alpha agonists, topiramate) should be considered if a rapid effect is sought or there is poor feasibility or adherence to behavioural treatments. Deep brain stimulation of the centromedian/parafascicularis thalamic nuclei or globus pallidus internus should be considered for patients refractory to less active interventions, but more evidence is required to support target selection and identify predictors of response to this invasive approach.