Treatment
For many patients and the families affected, the diagnosis itself is a significant relief. In the case of children, the education of teachers is of great importance. In all patients with Tourette's syndrome, it is important to check whether psychiatric comorbidities - such as obsessive-compulsive disorder, ADHD or depression - exist in addition to the tics, as these often lead to a far greater impairment of quality of life than the tics and therefore usually need to be treated as a priority.
When assessing the effectiveness of a treatment, the spontaneous fluctuations of the tics must be taken into account. Treatment recommendations for tics are not dependent on the type of tic or tic disorder and also apply to symptomatic tics. The treatment of children does not differ fundamentally from that of adults. However, transient tic disorder, which only occurs in children, usually has a particularly benign course and hardly ever requires treatment due to the low level of symptoms and self-limiting course.
Information from the Tourette Society Germany e.V. (TGD):
Neuroleptics are considered the substances of first choice in the treatment of tics, even though they quite often lead to adverse drug reactions. All medications should be dosed gradually and increased slowly until a positive effect or intolerable side effects occur.
Typical neuroleptics
Haloperidol (trade name: Haldol) is still the only drug approved in Germany for the treatment of Tourette's syndrome. The effect of haloperidol and also of pimozide is considered proven. However, due to severe side effects (most frequently fatigue, weight gain and sexual dysfunction), both substances are only to be classified as reserve preparations. Other classic neuroleptics have no significance in the treatment of tics in Germany.
Atypical neuroleptics
Tiapride (trade name: Tiapridex) has been the drug of choice for children in Germany for years. Most common side effects: Fatigue, dizziness, appetite and weight gain, hyperprolactinemia and sexual dysfunction.
Sulpiride (trade name: Dogmatil) only a few uncontrolled studies are available that suggest a positive effect of sulpiride on tics (and possibly also on compulsions).
Risperidone (trade name: Risperidal) is by far the best-studied drug. It leads to a 41-62% reduction in tics in both children and adults.
Aripiprazole (trade name: Abilify) is relatively new (only admitted in Germany in 2004) but there are already numerous case reports of positive treatment results. In contrast to other neuroleptics, it does not lead to weight gain, prolactin increase and sexual dysfunction, and rarely to extrapyramidal motor symptoms. The most common side effects are restlessness, sleep disorders, but also drowsiness, headaches and gastrointestinal symptoms.
Noradrenergic substances
These drugs are primarily used in children and adolescents with tics and comorbid ADHD.
Clonidine (trade name: Catapresan) is a preparet for the treatment of ADHD, which can have a positive effect on the tics if a tic disorder is also present. The most common side effects are tiredness and dizziness.
Habit Reversal Training (HRT) is a behavioral therapy technique whose main element is the practice of alternative behavior. Patients with tics should consciously perceive the pre-tic feeling in order to perform an alternative movement that is incompatible with the execution of the tic before the tic occurs.
The exposure and response prevention (ERP) method aims to interrupt the automatism often described by patients with tics that a premonition must always be followed by a tic.
According to initial studies, both techniques lead to a tic reduction of 30-35%.
Botulinum toxin
Treatment with local botulinum toxin injections can be considered if individual low-fluctuation tics (caused by easily identifiable and accessible muscles) lead to relevant clinical impairment. According to previous experience, the effectiveness is best for motor tics in the face and neck. However, treatment successes with vocal tics have also been reported on several occasions.
Cannabinoids and cannabis medications
In addition to patient reports on the positive effects of Cannabis sativa on various symptoms of Tourette's syndrome, two small studies found evidence of a tic-reducing effect of delta-9-tetrahydrocannabinol (THC), the most psychotropically active ingredient of the cannabis plant. However, the effect is not considered proven. It has recently become possible to apply to the Federal Institute for Drugs and Medical Devices (BfArM) for treatment with a cannabis extract or herb as an alternative.
Surgical treatment using deep brain stimulation
According to small and mostly uncontrolled studies, deep brain stimulation not only leads to a reduction in tics, but also in psychiatric comorbidities such as compulsion, depression, anxiety and auto-aggression. However, the appropriate target point is still unclear. According to current knowledge, deep brain stimulation represents a promising treatment alternative for severely affected and therapy-resistant adult patients.