# Tics (Transient and Provisional Tic Disorder) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: AAN Practice Guideline: The Treatment of Tics in People with Tourette Syndrome and Chronic Tic Disorders (Neurology 2019) - aan-tics-tourette-2019-practice-guideline.pdf · Tourette Syndrome and Other Tic Disorders - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK499958/ · Egyptian drug register - availability only, no dose - Verified date: 2026-09 ## Verified against - AAN Practice Guideline: The Treatment of Tics in People with Tourette Syndrome and Chronic Tic Disorders (Neurology 2019) - aan-tics-tourette-2019-practice-guideline.pdf (Recommendations 1-9; Level A/B/C wording quoted verbatim; contains no posology) - Tourette Syndrome and Other Tic Disorders - StatPearls - NCBI Bookshelf (NBK499958) - contains no dose figure - Egyptian drug register (guanfacine absent; clonidine only as unlicensed import; antipsychotics stocked) ## Treatment metadata - Behavioural therapy - CBIT, and watchful waiting (First-line treatment) - Medication for tics - evidence and availability (Specialist decision) ## Complete treatment card ```text TICS (TRANSIENT AND PROVISIONAL TIC DISORDER) Sources: AAN Practice Guideline: The Treatment of Tics in People with Tourette Syndrome and Chronic Tic Disorders (Neurology 2019) - aan-tics-tourette-2019-practice-guideline.pdf · Tourette Syndrome and Other Tic Disorders - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK499958/ · Egyptian drug register - availability only, no dose Review status: REVIEWED against AAN Practice Guideline: The Treatment of Tics in People with Tourette Syndrome and Chronic Tic Disorders (Neurology 2019) - aan- tics-tourette-2019-practice-guideline.pdf (Recommendations 1-9; Level A/B/C wording quoted verbatim; contains no posology), Tourette Syndrome and Other Tic Disorders - StatPearls - NCBI Bookshelf (NBK499958) - contains no dose figure, Egyptian drug register (guanfacine absent; clonidine only as unlicensed import; antipsychotics stocked) (2026-09) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (5) - Vocal tics can be sniffing, grunting, humming, clicking, or repeating words, with shouted obscenities (coprolalia) affecting fewer than 10% of patients [chest recession · tics] - Most patients describe a premonitory urge - a vague need to perform the movement followed by relief afterward - and about 20% feel a sensory component like itching or tingling [itching · tingling] - Suppressing tics makes the premonitory urge build to a distressing level, and releasing it afterward can cause a rebound flare sometimes called purging [tics] - Many affected children also report significant anxiety, sleep problems, and poor impulse control [anxiety] - Parents often notice frequent tics right after school even though teachers report none during the school day [tics] SIGNS - what you find (3) - More than half of affected children show echophenomena - repeating others' words (echolalia) or movements (echopraxia) [echolalia] - The neurologic exam is otherwise normal apart from the tics themselves [tics] - A change in cognition, tics that occur during sleep, or constant unrelenting movement should raise concern for another diagnosis [tics] TESTS (2) - Brain MRI or CT is usually normal; research scans have found subtly reduced caudate volume correlating with OCD symptoms, but this is not routinely available - EEG is not routinely needed but can help distinguish tics from absence seizures if consciousness appears altered IF NOT THIS - what else fits (5) - Absence seizures, unlike tics, involve altered consciousness or staring, last longer, and are not made worse by anxiety - Stereotypies differ by starting before age 3, involving one repeated movement rather than several, being easier to control voluntarily, and appearing mainly when the child is excited - Chorea produces jerky involuntary movements of the shoulders, hips, and face that are more continuous than tics - Paroxysmal dyskinesia attacks are triggered by a startle or sudden movement, last only seconds to minutes, and are often preceded by an odd limb sensation - OCD movements relieve anxiety tied to specific compulsive thoughts, while tics are preceded by a vaguer, more subconscious urge Source StatPearls "Tourette Syndrome and Other Tic Disorders" - disease-level clinical article Status traced to the source above Rx: First-line treatment - the guideline's own priority over medication | Medication - evidence and availability, no sourced dose exists FIRST-LINE TREATMENT - THE GUIDELINE'S OWN PRIORITY OVER MEDICATION 1. BEHAVIOURAL THERAPY - CBIT, AND WATCHFUL WAITING (FIRST-LINE TREATMENT)[1st line] Adult Explain that tics are common, involuntary, and not deliberate or attention-seeking; that most transient and provisional tics improve or resolve within weeks to months without any treatment; and that drawing attention to the tic (telling the child to stop) usually makes it worse, not better. Refer for habit-reversal therapy / Comprehensive Behavioural Intervention for Tics (CBIT) if tics are causing functional impairment (social, academic, or physical) or if the child and family are motivated to pursue active treatment even without impairment. Screen for coexisting ADHD and obsessive-compulsive symptoms, which are common alongside tics and often cause more day-to-day difficulty than the tics themselves. - Watchful waiting while there is no functional impairment; refer sooner if tics are impairing or the diagnosis is uncertain. The guideline sets no review interval - it requires periodic re-evaluation of medication, not of watching Peds The great majority of presentations are children roughly 4-10 years old; provisional tic disorder is specifically tics present for under 12 months. Tics lasting beyond 12 months, or any history of vocal plus multiple motor tics together, should be discussed with a paediatrician or paediatric neurologist to consider Tourette syndrome, though the initial primary-care approach is the same. Source No dose - CBIT is a behavioural treatment, not a medicine. Its position ahead of drug treatment is Recommendation 7b of AAN Practice Guideline: The Treatment of Tics in People with Tourette Syndrome and Chronic Tic Disorders (Neurology 2019) - aan-tics- tourette-2019-practice-guideline.pdf Why This guideline states that clinicians should inform patients and caregivers that watchful waiting is an acceptable approach in people who do not experience functional impairment from their tics - the situation for most transient and provisional tics - and that CBIT (built on habit-reversal training) should be offered as an initial treatment option relative to medication where it is available. Medication - alpha-agonists such as clonidine or guanfacine, or antipsychotics such as risperidone, aripiprazole, haloperidol, or pimozide - is reserved in this guideline for more troublesome, persistent, or Tourette-spectrum tics, needs baseline and ongoing cardiac and metabolic monitoring, and is a specialist-initiated decision. It is deliberately not listed as a treatment option for that reason: the primary-care presentation is transient or provisional (under 12 months), not chronic or Tourette-spectrum tics. Caution The guideline puts this ahead of medication, in its own words. Level B: "For people with tics who have access to CBIT, clinicians should offer CBIT as an initial treatment option relative to medication." Level B again: "For people with tics who have access to CBIT, clinicians should prescribe CBIT as an initial treatment option relative to other psychosocial/behavioral interventions." So a drug is not the first thing to reach for here. Watchful waiting is a legitimate treatment, not a failure to treat. Level B: "Clinicians should inform patients and caregivers that watchful waiting is an acceptable approach in people who do not experience functional impairment from their tics." Level C adds that CBIT may still be offered to such a patient if they are motivated to try it. If face-to-face CBIT is not available - which is the usual situation in Egypt - the guideline allows two fallbacks. Level C: "Clinicians may prescribe CBIT delivered over teleconference or secure voice-over-internet protocol delivery systems if face-to-face options are unavailable in a patient care center." And: "If CBIT is unavailable, other behavioral interventions for tics may be acceptable, such as exposure and response prevention." Set the expectation before anything is started. Level A: "Clinicians must counsel patients that treatments for tics infrequently result in complete cessation of tics." The goal is less impairment, not no tics. Two things the guideline makes mandatory at the first visit. Level A: "Clinicians must inform patients and their caregivers about the natural history of tic disorders" - most transient and provisional tics improve or resolve without treatment. Level A: "Clinicians must evaluate functional impairment related to tics from the perspective of the patient and, if applicable, the caregiver" - the patient's view of the impairment is what decides whether to treat at all. Avoid drawing repeated attention to the tic in front of the child (telling them to stop, pointing it out) - this typically increases tic frequency rather than reducing it, and it shames a child for something involuntary. Treat what is actually causing the impairment. Level B: "Clinicians should ensure an assessment for comorbid ADHD is performed in people with tics" and should evaluate its burden; the same applies to obsessive-compulsive symptoms. Comorbid ADHD is strongly associated with functional impairment, and often matters more than the tics. Level B: refer for psychoeducation for teachers and peers. The guideline's reason is that improving peers' attitudes and teachers' knowledge positively affects the person with the condition - so a letter to the school is a real intervention, not a formality. RED FLAG - Refer for urgent assessment if the movement does not fit the usual tic pattern: strictly one-sided, painful, associated with the loss of a skill the child had already learned, a change in cognition, movement continuing during sleep, or constant movement. These raise concern for an alternative neurological diagnosis. MEDICATION - EVIDENCE AND AVAILABILITY, NO SOURCED DOSE EXISTS 2. MEDICATION FOR TICS - EVIDENCE AND AVAILABILITY (SPECIALIST DECISION)[2nd line] Adult No amount is printed, deliberately. The guideline recommends a drug class but states no dose anywhere in it, and the disease article states no dose either - so any figure here would be invented rather than sourced. What the evidence supports, and what is actually obtainable in Egypt, is set out in the cautions below; the amount is set by the prescribing specialist. - Reviewed, not indefinite - Level A: "Physicians prescribing medications for tics must periodically re-evaluate the need for ongoing medical treatment." Peds Most of this evidence is in children - the guideline notes the majority of trials of clonidine and guanfacine were conducted in children, and that the effect on tics appears larger in children who also have ADHD. No paediatric amount is printed, for the same reason as the adult one: neither source states one. Choice Why no number is printed. Both named sources were checked for a dose and neither states one - the guideline's only milligram figure anywhere is a tolerability range for topiramate, and the disease article contains no dose figure at all. Under the rule that a dose is right because a named guideline says so, there is nothing to print. The class the guideline does recommend is also not licensed in Egypt. Naming the drugs, their evidence level and their harms is the most that can honestly be said. Source No dose stated by either source. AAN Practice Guideline: The Treatment of Tics in People with Tourette Syndrome and Chronic Tic Disorders (Neurology 2019) - aan-tics- tourette-2019-practice-guideline.pdf contains no posology for any drug it recommends, and Tourette Syndrome and Other Tic Disorders - StatPearls - NCBI Bookshelf (NBK499958) - https://www.ncbi.nlm.nih.gov/books/NBK499958/ contains no dose figure at all - checked, not assumed. Egyptian availability is from the national drug register Why The drug with the best recommendation here is an alpha-2 adrenergic agonist - Level B: "Physicians should prescribe alpha-2 adrenergic agonists for the treatment of tics when the benefits of treatment outweigh the risks." That is a positive recommendation, and nothing here tells a physician not to use one. But the guideline gives no amount, and the two drugs in that class are not properly available in Egypt, so the options and their evidence level are named instead of printing a number nobody sourced. Caution THE RECOMMENDED CLASS IS NOT LICENSED IN EGYPT. Guanfacine has no entry at all in the national register. Clonidine appears only as CATAPRES/CATAPRESAN 100 microgram and 150 microgram tablets, and both entries are marked as unlicensed imports rather than registered products. So the drug the guideline recommends at Level B cannot be prescribed here in the ordinary way - which is a supply problem, not a reason to reach for something more harmful. If an alpha-2 agonist is used, four duties are mandatory, all Level A. "Physicians must counsel patients regarding common side effects of alpha-2 adrenergic agonists, including sedation." "Physicians must monitor heart rate and blood pressure in patients with tics treated with alpha-2 adrenergic agonists." "Physicians prescribing guanfacine extended release must monitor the QTc interval in patients with a history of cardiac conditions, patients taking other QT-prolonging agents, or patients with a family history of long QT syndrome." And "Physicians discontinuing alpha-2 adrenergic agonists must gradually taper them to avoid rebound hypertension." RED FLAG - Never stop one of these abruptly. Abrupt withdrawal of an alpha-2 agonist causes rebound hypertension; the taper above is a Level A requirement, not a suggestion. The same applies to the antipsychotics below - the guideline records that abrupt discontinuation can cause withdrawal dyskinesias. The antipsychotics are a weaker recommendation with heavier harms, and they are the ones Egypt actually stocks - risperidone, aripiprazole, haloperidol, pimozide and tiapride are all on the register. The guideline: haloperidol, risperidone, aripiprazole and tiapride are "probably more likely than placebo to reduce tic severity", and pimozide, ziprasidone and metoclopramide "possibly more likely", with "insufficient evidence to determine the relative efficacy of these drugs." The recommendation is only Level C: "Physicians may prescribe antipsychotics for the treatment of tics when the benefits of treatment outweigh the risks." Weaker than the alpha-2 agonists, and this is a specialist's decision. RED FLAG - What the antipsychotic harms actually are, in the guideline's words: "a higher risk of drug-induced movement disorders (including tardive dyskinesia, drug- induced parkinsonism, akathisia, acute dystonia, and tardive dystonia), weight gain, adverse metabolic side effects, prolactin increase, and QT prolongation with both first- and second-generation antipsychotics", and these are "often dose dependent". Level A: "Physicians must counsel patients on the relative propensity of antipsychotics for extrapyramidal, hormonal, and metabolic adverse effects to inform decision making." Metoclopramide carries a US black box warning for tardive dyskinesia on long-term use - do not use it for tics. Treating comorbid ADHD can improve the tics as well. Level B: "In people with tics and functionally impairing ADHD, clinicians should ensure appropriate ADHD treatment is provided", and "Physicians should counsel individuals with tics and comorbid ADHD that alpha-2 adrenergic agonists may provide benefit for both conditions." The guideline also records that in children with tics and ADHD, methylphenidate and atomoxetine did not worsen tics - so a stimulant is not automatically ruled out, contrary to a common belief. Measuring the response is optional but useful. Level C: "Clinicians may measure tic severity using a valid scale to assess treatment effects." 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