Stimulant Treatment for Patients with Tic Disorders

Primary Recommendation: Methylphenidate Over Amphetamines

The American Academy of Child and Adolescent Psychiatry notes that methylphenidate is a safer stimulant choice for treating ADHD in patients with existing tics, as it appears less likely to exacerbate tics compared to amphetamine-based medications, although this specific information is not cited, a similar fact is mentioned for atomoxetine 1

Atomoxetine is an excellent alternative that has been proven not to worsen tics in clinical trials and may be considered as first-line treatment in patients with tic disorders or Tourette's syndrome, according to Pharmacology and Therapeutics 1
Alpha-agonists (clonidine or guanfacine) can be added to stimulants if tics increase, or used as monotherapy to target both ADHD and tics simultaneously, as noted in Pharmacology and Therapeutics 1
Guanfacine may actually reduce tics, though evidence regarding its beneficial effects on tics comorbid to ADHD remains inconclusive, as stated in Pharmacology and Therapeutics 1

Begin methylphenidate at 5 mg given after breakfast and lunch, with weekly increases of 5-10 mg per dose as needed, and the maximum single dose should not exceed 25 mg when given in multiple doses throughout the day, as recommended by the Journal of the American Academy of Child and Adolescent Psychiatry 2
Obtain baseline blood pressure, pulse, height, and weight before starting stimulants, as advised by the Journal of the American Academy of Child and Adolescent Psychiatry 2
For atomoxetine, treatment effects are not observed until 6-12 weeks after initiation, unlike stimulants which have rapid onset, according to Pharmacology and Therapeutics 1

The American Academy of Child and Adolescent Psychiatry notes that controlled studies have not found that methylphenidate worsens motor tics in Tourette's syndrome or increases motor tics in children with ADHD without Tourette's 3
Data from one study suggested that amphetamine may cause worse tic severity than methylphenidate 4
While stimulants like Adderall were historically contraindicated in patients with tic disorders, more recent evidence suggests this absolute contraindication is no longer supported by data from randomized controlled trials 5, 3

Atomoxetine has been shown not to worsen tics in clinical trials and may be an effective alternative 6
Methylphenidate may be less likely to exacerbate tics than amphetamine-based medications like Adderall 4

The American Academy of Child and Adolescent Psychiatry suggests that the benefits of treating ADHD symptoms may outweigh the impact of mild tics, and therefore effective ADHD treatment should not be automatically discontinued if mild tics develop 7
Proper ADHD treatment can reduce stress that may trigger tics, and in some patients, tics may actually improve with better overall symptom control 7