Dr. Danish's Guide to Tourette Syndrome and Tic Disorders
Dr. Danish has worked with treatment-resistant tic disorders and Tourette syndrome for 20 years and keeps up to date with the latest research. He understands it's complex with a myriad of causes spanning genetics, inflammation, stress, and medication side effects. This guide aims to provide a detailed overview of Tourette syndrome, its risk factors, and the various treatment options available.
Defining Tic Disorders vs. Tourette Syndrome
Tic disorders are characterized by sudden, repetitive movements or sounds. Tourette syndrome is a specific type of tic disorder that involves both motor and vocal tics lasting for more than a year. Tics can range from simple (like blinking or throat clearing) to complex (like coordinated movements or phrases). Stress, fatigue, or excitement can worsen tics, while focused attention or physical activity can improve them.
Risk Factors for Tourette Syndrome
Several factors increase the risk of developing Tourette syndrome:
Genetics: A strong genetic component is involved, with several gene variants linked to the disorder. Genetic studies have identified pathways related to cell adhesion, neurotransmitter signaling, and neuroimmunity.
Inflammation: Allergic conditions like asthma and eczema are associated with higher tic disorder prevalence. A systematic review found significant associations between tic disorders and allergic conditions, including asthma, allergic rhinitis, and eczema. Certain infections, such as strep or various viruses, can also bring on tics. For more on PANS and PANDAS, visit this blog, or learn more about our providers who specialize in PANS & PANDAS, here.
ADHD: Attention-deficit/hyperactivity disorder often co-occurs with Tourette syndrome, complicating the clinical picture and treatment approach.
Gender: Males are more likely to develop Tourette syndrome than females, with a male-to-female ratio of approximately 4:1.
Age: Symptoms typically appear between ages 5 and 10, with the severity peaking around age 10 and often improving during adolescence.
Therapy Treatment of Tourette Syndrome
Comprehensive Behavioral Intervention for Tics (CBIT): CBIT is highly effective in reducing tics, with studies showing a 26-31% reduction in tic severity. It includes habit reversal training and competing response training to increase awareness of tics and suppress them. CBIT has been adapted for various age groups and settings, including virtual formats.
Exposure and Response Prevention (ERP): This therapy gradually suppresses tics by increasing tolerance to premonitory urges. ERP exposes patients to the unpleasant sensation associated with a premonitory urge, helping them resist the tic. It can be an alternative if CBIT is unavailable and has shown significant efficacy in reducing tics without significant adverse effects.
Current Medication Options
Alpha-2 Adrenergic Agonists: Clonidine and guanfacine are first-line treatments due to their safety profiles. Clonidine has been shown to be more effective than placebo at reducing tics and is comparable to haloperidol. Guanfacine has mixed results but is often chosen over clonidine due to less sedation.
Clonidine is a non-stimulant medication that has evidence for ADHD, anxiety, irritability, and insomnia.
Intuniv/Guanfacine for ADHD: Discover the benefits of Intuniv/Guanfacine for managing ADHD symptoms, providing a non-stimulant option for treatment.
Antipsychotics: The most effective medications are antipsychotics, such as Aripiprazole, risperidone, and pimozide. However, this class of medications comes with unique side effects which limit their use to more severe cases. Aripiprazole is more well-tolerated than other medications in this class.
For more on Abilify (aripiprazole), including dosing and side effects, visit this blog.
For more on the unique and rare movement disorder side effect that can arise with longer term use of antipsychotics, called Tardive Dyskinesia, read this blog.
Dopamine agonists that have shown potential in treating tics off-label include:
Pramipexole: Pramipexole, another medication commonly used for Parkinson's disease and restless legs syndrome, has also been investigated for its potential to reduce tic severity. It acts on dopamine D2 and D3 receptors, which may help modulate tic activity. A placebo-controlled trial of pramipexole is in progress, indicating ongoing research interest in its efficacy for tic disorders.
Read this blog on the dosing and potential side effects of Pramipexole.
Ropinirole: Ropinirole, primarily used for Parkinson's disease and restless legs syndrome, has been used off-label for reducing tics. The presumed mechanism is through presynaptic receptors in the striatum, which may help modulate tic activity. If used, we would start with the ER preparation at 2mg daily and consider a maximum dose of 4mg daily 2 weeks later.
VMAT2 Inhibitors: Tetrabenazine and deutetrabenazine have shown promise in open-label studies, although larger trials have had mixed results. These medications are often reserved for refractory cases.
Read this blog for more on the dosing and potential side effects of deutetrabenazine.
Cannabinoids: THC and CBD compounds have shown potential in reducing tics. A single dose of THC led to significant tic reduction, and ongoing trials are exploring the efficacy of various cannabinoid formulations.
Read this blog for the potential pitfalls of medical marijuana.
Read this blog for the dosing, efficacy, and potential side effects of CBD.
Stimulants: While they can sometimes worsen or even bring on tics, in some cases they are known to treat tics. The use of stimulants requires careful monitoring to balance the benefits and potential risks.
Future Medications
Ecopipam: A dopamine D1-receptor antagonist showing promise in reducing tic severity, pending FDA approval. Ecopipam has shown significant improvement in tic scores in children, making it a potential future treatment option.
NeuroModulation Approaches
Transcranial Magnetic Stimulation (TMS): A review found that low-frequency rTMS targeting the supplementary motor area (SMA) was particularly effective, with approximately 62.5% of OCD studies and 85.7% of TD studies showing significant clinical improvements. The most effective dosing involved low-frequency rTMS (1 Hz) administered once a day, 5 days per week, for 2-6 weeks, with each session lasting 10-30 minutes and delivering 750 to 60,000 pulses. The review also highlighted that rTMS is generally safe and well-tolerated, with minimal side effects reported.
Transcranial Direct Current Stimulation (tDCS): tDCS involves applying a low electrical current to the brain, showing significant reductions in tic severity in some studies. Cathodal tDCS over the supplementary motor area or motor cortex can lead to significant reductions in tic symptoms, with some effects sustained for up to six months. However, further research is needed to optimize stimulation parameters and confirm long-term efficacy.
Deep Brain Stimulation (DBS): DBS is a promising treatment for severe, treatment-refractory Tourette syndrome. It involves implanting electrodes in specific brain regions to modulate neural activity. Studies have shown significant tic reduction, with improvements in tic severity ranging from 45.1% to 52.7%.
Supplement Treatments
Vitamin B6 and Magnesium Glycinate:
Magnesium glycinate and Vitamin B6 have been explored as potential treatments for tic disorders, including Tourette Syndrome (TS). Magnesium glycinate is often recommended due to its better absorption and fewer gastrointestinal side effects compared to other forms of magnesium (Dr. Danish also like Magnesium-L-Threonate for these same reasons). Magnesium is thought to help reduce tics by stabilizing nerve cells and reducing excitability, which can help manage the involuntary movements associated with tic disorders.
Vitamin B6 (pyridoxine) is often used in combination with magnesium to enhance its effects. It is considered safe and has a wide therapeutic margin.
For dosing, it is recommended to start with a combination of 0.5 mEq/Kg magnesium and 2 mg/Kg vitamin B6, divided into morning and dinnertime doses (BID). The titration schedule involves beginning at 1/3 of the full dose for the first week, increasing to 2/3 of the full dose in the second week, and reaching the full dose by the third week.
It is important to continue the treatment for at least 4 months before evaluating its efficacy.
Regular monitoring for any side effects, particularly gastrointestinal issues, is essential, and the dose should be adjusted if necessary. Always consult with a healthcare provider before starting any new supplement regimen, especially for children. By following this structured approach, you can systematically assess the potential benefits of magnesium glycinate and vitamin B6 for managing tic disorders in pediatric patients.
Vitamin B6 & L-Theanine: A study involving a combination of L-theanine (200 mg/day) and low-dose vitamin B6 (2.8 mg/day) showed that 71% of participants were responders, with a 30% decrease in YGTSS total tic score.
Vitamin D3: Correcting deficiencies can improve tic symptoms. At least one study has demonstrated that vitamin D3 supplementation led to significant improvement in tic symptoms.
Read our blog on the importance of Vitamin D3 supplementation, but only in those who need it.
Taurine:
Taurine is an amino acid that acts as a GABA-receptor agonist, with typical dosing for tic disorders ranging from 500 mg to 2000 mg per day, often divided into multiple doses. It is believed to exert its effects by modulating the GABAergic system, which plays a role in inhibitory neurotransmission and may help reduce tic severity. Studies have shown that taurine, when added to tiapride (a dopamine antagonist), significantly improved tics compared to placebo, without significantly more adverse events.
Taurine is generally well-tolerated, with potential side effects being rare but possibly including mild gastrointestinal discomfort, headache, and dizziness. Long-term safety data are limited, so monitoring for any adverse effects is recommended.
Traditional Chinese Medicine (NDG and 5-LGr):
Ningdong Granule (NDG): NDG is a traditional Chinese medicine composed of eight Chinese herbs, 4-Hydroxybenzaldehyde, and three animal substances, including human placenta. These ingredients are processed and combined to form granules, leveraging traditional therapeutic principles to treat conditions like ADHD by modulating neurotransmitter levels and reducing symptoms. The exact dosing regimen can vary, but it is typically administered in granule form, dissolved in water, and taken orally. There is evidence, mostly out of China, that supports its use for both ADHD and Tic Disorder/Tourette’s.
5-Ling Granule (5-LGr): 5-LGr contains 11 different herbs and is administered similarly to NDG, typically in granule form. Similar to NDG, the studies are out of China. In those studies, close to 70% of patients respond well and side effects are uncommon.
In the studies out of China, dosing is vague but both NDG and 5-LGr are noted to be well-tolerated. Reported side effects are minimal and may include mild gastrointestinal discomfort. However, the long-term safety profile of these herbal treatments requires further investigation and it’s hard to research the quality of these supplements sold online.
Getting in Touch with Dr. Danish and His Team
At Philadelphia Integrative Psychiatry, we specialize in diagnosing and treating Tourette syndrome and tic disorders. Our holistic and integrative approach ensures that we consider all aspects of our patients' well-being in developing personalized treatment plans. If you or a loved one are seeking support for Tourette syndrome or similar conditions, please text or call 610-999-6414 to learn how we can help.
For more on this topic and related subjects, check out these blogs:
Intuniv/Guanfacine for ADHD: Discover the benefits of Intuniv/Guanfacine for managing ADHD symptoms, providing a non-stimulant option for treatment.
Strattera (Atomoxetine) for ADHD: Explore the role of Strattera (Atomoxetine) in the treatment of ADHD, offering an alternative to traditional stimulant medications.
Magnesium and Mental Health: Investigate the positive impacts of Magnesium on ADHD, depression, anxiety, and its potential role in preventing dementia.
Iron Levels and ADHD: Examine the link between low iron levels and ADHD, shedding light on the importance of monitoring and managing iron for optimal mental health.
