Synopsis
Identify motor and vocal tics from their urge, stereotypy and suppressibility, diagnose Tourette syndrome longitudinally, assess comorbid ADHD and obsessive-compulsive symptoms, and reserve treatment for meaningful distress or impairment.
- A tic is a sudden, rapid, recurrent, non-rhythmic motor movement or vocalisation that is stereotyped for the individual and often temporarily suppressible at the cost of mounting inner tension.
- Many people describe a premonitory urge relieved briefly by performing the tic; young children may not recognise or verbalise this sensation.
- Tics wax and wane, change anatomical site and complexity, and commonly increase with fatigue, excitement, anxiety or attention drawn to them; fluctuation does not imply deliberate behaviour.
- Tourette syndrome requires multiple motor tics and at least one vocal tic during the course, beginning before adulthood and persisting for more than a year, although they need not occur together continuously.
- Coprolalia is neither universal nor required. Sniffing, throat clearing, blinking, grimacing, shoulder movements and head jerks are more typical presentations.
- ADHD, obsessive-compulsive symptoms, anxiety, autism, rage episodes, sleep problems and learning difficulty may cause more impairment than the tics and should be assessed on their own merits.
- No blood test, MRI or EEG is routinely required for a classic developmental tic history with a normal neurological examination; investigate atypical onset or examination instead.
- Psychoeducation and school or workplace adjustments are treatment: asking someone to stop, punishing tics or repeatedly highlighting them can increase distress and symptoms.
- When tics materially impair quality of life, behavioural therapy such as habit reversal or comprehensive behavioural intervention is generally preferred before medicine.
- Drug treatment is specialist-led and target-based because sedation, metabolic effects, hypotension and drug-induced movement disorders can outweigh partial tic reduction.
Key red flags
Acute chorea, fixed dystonic posture, rhythmic tremor, seizures, progressive focal signs or a new adult-onset movement without childhood history should not be forced into a tic diagnosis.
Investigation priorities
Confirm onset, duration, changing motor and vocal phenotypes and the diagnostic time criterion.
Management branches
Recurrent movements or sounds are reported in a child or adult.
- 1. Ask the person to describe urge, relief, suppressibility, rebound, triggers and whether the movement or sound is recognisably the same each time.
- 2. Reconstruct all previous motor and vocal tics and duration, using home video and collateral information with consent.
- 3. Examine for chorea, dystonia, weakness, ataxia, seizures and developmental or psychiatric comorbidity, escalating sudden or progressive atypical signs.
- 4. Name the tic disorder only to the level the time course supports and explain that symptoms are involuntary despite partial suppression.
Key medicines
ClonidineA specialist may begin with a low evening oral dose and titrate slowly in divided doses, especially when tics coexist with ADHD; follow current BNF and local age-specific guidance.Monitor blood pressure, pulse, sedation, dizziness and constipation. Avoid abrupt withdrawal because rebound hypertension can occur, and explain that benefit may take several weeks.
AripiprazoleUse a specialist-selected low once-daily starting dose with gradual increments towards the minimum that meets the agreed tic or behavioural goal.Discuss akathisia, sedation, nausea, impulse-control problems and metabolic effects, and monitor for parkinsonism and tardive dyskinesia. It is not justified for mild socially acceptable tics.