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MOCA: Motor Tics

Kiarash Sadrieh, MD and Solomon Behar, MD
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Sol reviews the diagnosis and management of tic disorders in childhood with Kiarash Sadrieh, Pediatric Neurologist and Associate Professor of Pediatrics at CHLA.

  • A tic is a sudden, brief, rapid movement or vocalization that is semi-voluntary but unpredictable.  Tics are recurrent, repetitive and nonrhythmic.

  • Patients are able to suppress tics for a certain amount of time; however, the urge to tic will become overwhelming and once the patient expresses the tic often there is a sense of relief.

  • Tics start usually at the age of 4-6 years(anything earlier is generally a motor stereotypic movement and not a tic) with a peak incidence between 8-12.

    • Tics can be classified as motor versus vocal versus sensory; simple versus complex.

    • A simple motor tic involves one muscle group, is brief and not a series of movements

    • A complex motor tic can be a series of movements

    • A simple vocal tic could be throat clearing, sniffling or coughing

    • A complex vocal tic could be an entire phrase

      • The classic Tourette vocalization is coprolalia (but only happens in about 20% of patients)

      • Echopraxias (absolute phrases) are a lot more common

    •  Sensory tics may be just feelings

  • The tic differential diagnosis includes:

    • movement disorders, shuttering spells or seizures, ingestion/drug use, carbon monoxide poisoning, post-viral encephalitis, Wilson’s disease and/or other conditions that affect the basal ganglia (and in which you can have secondary or symptomatic tics)

  • Common comorbidities include:

    • ADHD, OCD, learning disabilities, mood and sleep disorders, secondary hypersensitivity

  • There is no set diagnostic criteria for motor tics therefore it is a clinical diagnosis.  Therefore, a good history (emphasis on the waxing and waning pattern) and physical examination (usually unremarkable neurologic exam for an idiopathic tic disorder) is key. 

    • Ancillary study that may be considered, but not routinely needed, include: TSH, Free T4, anti-DNAseB, and ASO titers

  • Tics appear in the background of normal activity and there shouldn’t be an alteration in mental status.

    • Tics can also occur in sleep as well

  • Stress, anxiety, physical activity, excitement, fatigue, infection, heat and medications (dopaminergic, steroids, stimulants, caffeine) can all increase or unmask tics.

  • Tics can go into remission too; often when there is full engagement in a mental or physical activity.  While not recommended, cannabinoids, ethanol and nicotine all decrease tic severity and frequency.

  • Tics cluster in families and can be considered a polygenic disease.

  • The natural history of tics is benign and self-limited (differentiated from Tourette’s disease) and in adolescence there is usually improvement.

    •  1/3 of patients will have a resolution of tics

    • 1/3 of patients will have improvement of tics

    • 1/3 of patients will have fluctuation of tics

  • The first step in tic management is psych-education: specifically reassurance.  The advice is to ignore the tics so that there is no negative or positive feedback to the patient.

    • If further symptomatic therapy is needed (because they are painful, causing injury or functional impairment, obstructing activities of daily living, and/or severe social distress) options include:

  • Cognitive Behavioral Therapy (CBT)/habit reversal therapy (although not always covered by insurance and the patient must be old enough/engaged enough to participate)

  • First-line medications include alpha-2-antagonists: clonidine and guanfacine

    • An example of a treatment regimen for an adolescent may include: 0.5 mg of guanfacine QHS for 1-3 days, then BID for 3 days, and then a week later increase by 0.5 mg per dose until a max of 3 mg/day.

  • Second-line medications include neuroleptics (aripiprazole, risperidone) and dopamine antagonists.  At this point, referral to neurology or psychiatry is suggested.

    • After starting medication, follow should be between 6 weeks-3 months; once the regimen is stable, follow-ups can be spaced out.  After about 12-15 months weaning off the medication can be considered.

  • Treating any underlying comorbidity is also an important part of the treatment plan.

  • Transient tic disorder: motor and/or vocal tics for less than one year

  • Chronic tic disorder: motor or vocal tics for greater than one year

  • Tourette’s syndrome: motor and vocal tics for greater than one year

    • For patients living with Tourette’s, a great video is linked here 

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Hippo Peds RAP May 2021 Written Summary 188 KB - PDF

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