Treatment of Tics

Diagnosis and Classification

• The American Academy of Child and Adolescent Psychiatry recommends using the term "tic cough" instead of "habit cough" or "psychogenic cough" for children with chronic cough that persists after a thorough evaluation, and diagnosis of tic cough should be made when the patient manifests central clinical characteristics of tics, including suppressibility, distractibility, suggestibility, variability, and presence of premonitory sensation 1
• The diagnosis of tic cough should be based on clinical characteristics, and not on the presence or absence of nocturnal cough or barking cough 2
• The DSM-5 classification system recognizes tic disorders, including transient tic disorder, as a distinct condition rather than using older terms like "habit" or "psychogenic" movements, according to the American Psychiatric Association 1

Comorbidities

• Comorbidities such as attention-deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) are common in patients with Tourette syndrome, with ADHD present in 50-75% of patients and OCD present in 30-60% of patients 1, 2
• Psychological stress, fatigue, and high altitude can trigger or worsen tics, while trauma exposure can contribute to neurobiological changes that may manifest as tics 2, 3, 4

Differential Diagnosis

• The following conditions should be considered in the differential diagnosis of tic disorders:

  Condition	Characteristics
  Psychogenic movement disorders	Distractibility, variability, suggestibility, and atypical response to medications
  Hyperekplexia	Excessive startle response to unexpected stimuli, present from birth
  Sandifer syndrome	Paroxysms of head tilt after eating, secondary to gastroesophageal reflux
  Benign paroxysmal torticollis	Recurrent episodes of abnormal head postures in infants
  Transient dystonia of infancy	Paroxysmal episodes of abnormal upper limb posture
  Chronic motor or vocal tic disorder	Similar to transient tic disorder but lasts more than one year, according to the American Psychiatric Association [2]
  Tourette syndrome	Features both motor and vocal tics for more than one year, as noted by the Tourette Association of America [2]

Treatment

• The American Academy of Child and Adolescent Psychiatry suggests that telepsychiatry and teletherapy are effective for the treatment of tics, with results comparable to in-person treatment 5
• Education and reassurance are the cornerstone of management, as educating patients and families about the benign, self-limiting nature of the condition is essential, as recommended by the American Academy of Pediatrics 2
• Watchful waiting is typically recommended for mild cases, given the transient nature and spontaneous resolution of the condition, as noted by the American Academy of Family Physicians 2
• Behavioral interventions, such as Habit Reversal Training (HRT) or Comprehensive Behavioral Intervention for Tics (CBIT), are recommended as first-line treatments for significant distress or functional impairment, as reported by the Association for Behavioral and Cognitive Therapies 2
• Alpha-2 adrenergic agonists, such as clonidine or guanfacine, are recommended as first-line medications, with moderate quality evidence supporting efficacy and a better side effect profile than antipsychotics 2
• Atypical antipsychotics, such as aripiprazole, are considered second-line medications, to be used when alpha-2 agonists are ineffective or poorly tolerated, with monitoring for metabolic side effects, weight gain, and extrapyramidal symptoms 2
• Antipsychotics, although effective, should be reserved for severe cases due to their side effects, such as weight gain, extrapyramidal symptoms, and metabolic effects, and should be used with caution in children with tic cough, as recommended by the American Academy of Child and Adolescent Psychiatry 2

Management and Prognosis

• Most cases of transient tic disorder resolve spontaneously within a year without treatment, as noted by the American Academy of Pediatrics 2
• Iatrogenic harm, resulting from misdiagnosis and excessive treatment, is a major morbidity in children with habit cough, a form of tic, as reported by the American Thoracic Society 2
• Patients can temporarily suppress tics, which helps differentiate them from conditions like chorea and dystonia, as noted by the American Neurological Association 2
• Tic episodes are very brief, typically shorter than paroxysmal kinesigenic dyskinesia attacks, as reported by the International Parkinson and Movement Disorder Society 6
• The American Academy of Pediatrics recommends avoiding iatrogenic harm from misdiagnosis and overtreatment, especially in children with tic cough, and emphasizes the importance of avoiding excessive medicalization of this condition 1