There is no known cure for Tourette's syndrome (TS). The goal of therapy is to reduce motor and vocal tics and alleviate associated behavioral problems, such as obsessive-compulsive behaviors, attention deficit/hyperactivity disorder (ADHD), and impulsivity. Behavioral management techniques performed at home, professional counseling, integrative therapies (such as relaxation therapy, biofeedback, and hypnosis), and some medications are effective methods for treating the condition. Brain surgery is currently being studied as a treatment for tics. In mild cases of tic disorder, very little treatment may be needed. Typically, tics increase when the child is tense or stressed, and decrease when the child is relaxed or focused on a task. The use of relaxation techniques or biofeedback may help the child deal with stress. Although some milder tic disorders may respond to behavioral therapies, TS generally does not. The best form of treatment is medication.
Medications: A majority of patients with TS do not need to take drugs, as their tics do not interfere much with their lives, and they develop normally.
Neuroepilectics: Drug therapy may include low doses of certain antipsychotic medications (called neuroleptics), such as haloperidol (Haldol®), pimozide (Orap®), aripiprazol (Abilify®), fluphenazine (Prolixin®), and risperidone (Risperdal®). These drugs may be effective in reducing the frequency and intensity of tics but should be prescribed with caution, since their use may be associated with certain severe side effects.
Side effects associated with neuroleptic therapy include the development of tardive dyskinesia (TD), a movement disorder characterized by persistent, repetitive (stereotypic) involuntary movements usually involving the lower face and mouth.
Neuroleptic therapy may also be associated with certain short-term side effects, such as drooling, contraction of the facial and neck muscles, bradykinesia (slow movement), akasthisia (restlessness), and other neurological symptoms.
Over the long-term, antipsychotics like risperidone can cause significant weight gain and may lead to diabetes.
Although TD sometimes resolves after a period of drug therapy, particularly in children, the condition is not always reversible. Therefore, those who receive long-term neuroleptic therapy should be periodically evaluated to monitor side effects and determine whether dosage level may be decreased or therapy may be discontinued.
Botulism injections: Injections of botulinum toxin (BTX or Botox®) into the muscles involved in tics may markedly alleviate not only the abnormal movements but also the premonitory sensations or urges that precede the tics. Pain during injection is usually minimal and subsides rapidly.
Other medications: The administration of the anti-anxiety medication clonazepam (Klonopin®) or certain antidepressant medications such as sertraline (Zoloft®), paroxetine (Paxil®), and fluoxetine (Prozac®), may be helpful in the management of some of the associated behavioral symptoms. The antidepressants may also be used for symptoms of obsessive-compulsive disorder (OCD). Side effects include impotence (inability of a man to have or maintain an erection), fatigue (excessive tiredness), weight gain, and drowsiness. Clomipramine (Anafranil®) is also commonly used to control obsessive-compulsive (OC) behavior.
Use of clonidine (Catapres®), guanfacine (Tenex®), or alpha 2-adrenergic agonists normally used in hypertension (high blood pressure) may relieve symptoms of ADHD and impulsivity, but these drugs are generally not very effective in controlling tics.
Medications may be used in combination when a single agent is only partially effective in reducing the symptoms of TS. Medications used in TS should be tapered gradually to avoid worsening of symptoms when the drug is discontinued. The doctor may simply observe an individual with TS for weeks or even months before starting drug treatment. Usually, after two to three years, TS will be as severe as it is going to get. In the late teenage years, tics often get better by themselves.
Psychotherapy: Psychotherapy does not directly impact TS or eliminate tics, but it may be beneficial to some TS patients who develop psychological problems as a result of the condition. The inability to control one's own body and even one's own thoughts can be a great source of anxiety, guilt, fear, helplessness, anger, and depression. Some patients react by withdrawal, others by aggression, and still others by perfectionism and excessive efforts to be in control. Since virtually all TS patients are subjected to some form of negative social reactions, self-esteem problems are common. In addition, TS patients experience all the difficulties associated with growing up with a chronic illness. For those reasons rather (and not for the primary symptoms of TS), counseling may be used.
Family treatment: As with any chronic illness, TS can cause great strain on the family as well as on the individual patient. Parents may have a harder time accepting their children's symptoms than the children themselves. Part of the trouble may lie in the guilt associated with the genetic nature of the disorder. Another major problem for parents is distinguishing between the behaviors that are beyond the control of the TS child and the behaviors that can be controlled. Spouses must work together to help solve the complex problems associated with taking care of TS patients. The goal for family members is to develop the flexibility to give special help when needed but not to overprotect.
Genetic counseling: With the recognition that TS is familial and genetic, families naturally have become interested in the possibility of genetic counseling. Such counseling must be provided by knowledgeable clinicians who can impart accurate information about the mode of transmission and work with families in dealing with the complex feelings that are aroused.
School and work issues: Since TS is an uncommon disorder, schools need to be informed about the nature of TS and the ways it affects attention and learning. Sometimes the doctor will actively serve as a child's advocate. Sometimes children's parents may be asked to keep the child at home if his or her symptoms are thought to be too disruptive for the classroom. This may deprive a child of his or her legal rights for the least restrictive educational environment and adequate education. Parents with children who have TS should seek professional advocacy and support if the child's symptoms are severely disrupting in school.
Many adults with TS require special modifications in their working situations. Often, an explanation to the employer about special needs will receive a positive response. Flexibility, compassion, and productivity in the workplace can be increased to everyone's benefit with appropriate interventions for a very symptomatic patient or for a patient who is having difficulty adjusting to a new medication.
Surgery: Although still in experimental stages, surgery is being increasingly used for symptomatic treatment of tics in TS. One surgery, called deep brain stimulation (DBS), involves implanting electrodes deep inside the brain, then connecting them under the skin to pacemaker devices on each side of the upper chest. These electrodes use mild electrical stimulation or "shocks" to decrease the neuronal (nerve) firing that causes tics. Some patients report being 85-90% tic-free after the surgery. Risks include infection, headache, and pain. DBS was approved by the U.S. Food and Drug Administration (FDA) in 1997 as a treatment for essential tremor and in April 2003 as a treatment for dystonia (a neurological movement disorder in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures). The FDA approved DBS for Parkinson's disease in 2002.
Although few clinical studies exist using integrative therapies for the treatment of Tourette's syndrome (TS), there have been studies in other neurological disorders that may present with similar symptoms. Listed below are integrative therapies that have been studies clinically in various neurological disorders.
Good scientific evidence
5-HTP: 5-HTP or 5-hydroxytryptophan is a naturally occurring amino acid in the body that helps make the neurotransmitter (brain chemical) serotonin. Cerebellar ataxia results from the failure of part of the brain to regulate body posture and limb movements. 5-HTP has been observed to have benefits in some people who have difficulty standing or walking because of cerebellar ataxia. Some research shows that 5-HTP may allow individuals with unsteady movements to stand alone without assistance, walk without aid, or improve coordination. Other research shows no benefit. Further research is needed before a conclusion can be drawn. 5-HTP may interact with other mood-altering medications such as antidepressants and anti-anxiety drugs.
Music therapy: Music therapy has been reported to improve symptoms in people with Parkinson's disease. Modest improvements were seen in symptoms including: motor coordination, speech intelligibility and vocal intensity, bradykinesia (slow movement), emotional functions, activities of daily living, and quality of life.
Omega-3 fatty acids: Omega-3 fatty acids are essential fatty acids found in cold water fish (including salmon, herring, and tuna) and other marine life (such as krill and algae). Omega-3 fatty acids can also be found in certain plants and nuts, including purslane and walnuts. An investigational drug for the symptomatic treatment of the neurological condition Huntington's disease (HD) is ethyl-EPA (Miraxion®), a pharmaceutical drug based on a component of omega-3 fatty acids called eicosapentaenoic acid (EPA). Miraxion® seems to help decrease the chorea (involuntary movements) that can be debilitating in individuals with HD. Omega-3 fatty acid supplements (including fish oils) may cause an increase in bleeding in sensitive individuals, including those taking blood thinning drugs such as warfarin (Coumadin®) or those with bleeding disorders. More research should be performed for the use of Miraxion® in other neurological disorders.
Unclear or conflicting scientific evidence
Acupressure, Shiatsu: The practice of applying finger pressure to specific acupoints (energy points) throughout the body has been used in China since 2000 B.C. Shiatsu technique involves finger pressure at acupoints and along body meridians (energy lines). It can incorporate palm pressure, stretching, massaging, and other manual techniques. Shiatsu practitioners commonly treat musculoskeletal and psychological conditions, including neck, shoulder, and lower back problems, arthritis, depression, and anxiety. Preliminary clinical evidence from one small study with individuals with facial spasms reports improvement when using Shiatsu acupressure. Further research is needed.
Acupuncture: Aucupuncture has been reported to help relieve symptoms of some neurological disorders including cerebral palsy, hemiplegia (full or partial paralysis of one side of the body due to disease, trauma, or stroke), Parkinson's disease (characterized by fine muscle coordination and tremors), spinal cord injury, Tourette's syndrome (characterized by "tics"), and trigeminal neuralgia. One study found that parents were impressed with acupuncture therapy on functional well-being in Huntington's disease in children. There is insufficient evidence available from well-designed studies for using acupuncture in neurological disorders such as Tourette's syndrome. More trials need to be performed.,
Alexander technique: The Alexander technique is an educational program that teaches movement patterns and postures, with an aim to improve coordination and balance, reduce tension, relieve pain, alleviate fatigue, improve various medical conditions, and promote well-being. Preliminary research suggests that Alexander technique instruction may improve fine and gross movements and reduce depression in patients with Parkinson's disease. Well-designed human trials are necessary.
Arginine: Arginine, or L-arginine, is considered a semi-essential amino acid, because although it is normally synthesized in sufficient amounts by the body, supplementation is sometimes required. Adrenoleukodystrophy (ALD) is a rare inherited metabolic disorder characterized by the loss of fatty coverings (myelin sheaths) on nerve fibers in the brain, and progressive destruction of the adrenal gland. ALD is inherited as an x-linked genetic trait that results in dementia and adrenal failure. Injections of arginine have been proposed to help manage this disorder, although most study results are inconclusive. Further research is needed to evaluate the use of arginine in ALD and other neurological conditions.
Chiropractic: Chiropractic is a healthcare discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system), and how this relationship affects the preservation and restoration of health. Although there is not enough reliable scientific evidence to conclude the effects of chiropractic techniques in the management of Parkinson's disease, anecdotal reports suggest a positive impact on fine muscle coordination in some individuals. More clinical research is necessary.
Coenzyme Q10: Coenzyme Q10, or CoQ10, is produced by the human body and is necessary for the basic functioning of cells. There is promising evidence from one case control study and two case series to support the use of CoQ10 in the treatment of symptoms associated with the neurological condition Friedrich's ataxia. These studies are lacking in sample sizes. A future randomized controlled trial with a substantial number of participants is necessary for proper evaluation of efficacy of CoQ10 in Friedrich's ataxia. Further research using CoQ10 for neurological conditions is necessary.
Ginseng: A clinical study found that patients with neurological disorders may improve when taking Asian ginseng (Panax ginseng). This supports research findings that report Panax ginseng improving cognitive function. More research is needed in this area.
L-carnitine: Although used traditionally for support of neurological conditions, one poorly designed preliminary clinical study reported that L-acetyl-carnitine (carnitine or L-carnitine, an amino acid derivative) possesses neither efficacy nor toxicity towards the patients with Huntington disease. Further trials are required to determine if L-carnitine is beneficial in individuals with neurological disorders.
Melatonin: Melatonin is a naturally occurring hormone that helps regulate sleep/wake cycles (circadian rhythm). Melatonin has been reported useful in neurological conditions including Parkinson's disease, periodic limb movement disorder, and tardive dyskinesia (TD, a movement disorder characterized by persistent, repetitive (stereotypic) involuntary movements usually involving the lower face and mouth). The use of melatonin in these conditions, however, is not supported by rigorous scientific testing. Better-designed research is needed to determine if melatonin is beneficial in individuals with neurological disorders.
Moxibustion: Moxibustion, a traditional Chinese medicine that contains mugwart, uses the principle of heat to stimulate circulation and break up congestion or stagnation of blood and chi (energy). One small study reported treatment of trigeminal neuralgia with cupping to have a significant therapeutic effect. However, there is insufficient available evidence and more clinical studies are needed in this area
Reiki: Reiki is a system of lying on of the hands that originated as a Buddhist practice approximately 2,500 years ago. One randomized trial suggests that reiki may have an effect on autonomic nervous system functions such as heart rate, blood pressure, or breathing activity, important in neurological disorders that may damage autonomic function including neurological conditions. Large, well-designed studies are needed before conclusions can be drawn.
Safflower:Friedreich's ataxia is a genetic neurodegenerative disease. In one clinical trial, safflower (Carthamus tinctoria) decreased deterioration caused by Friedreich's ataxia. More high-quality studies with larger sample sizes are needed to establish safflower's effect on neurological conditions.
Taurine: Taurine, an amino acid, may affect cellular hyperexcitability by increasing membrane conductance to potassium and chloride ions, possibly by altering intracellular (within the cell) availability of calcium. Results from a single non-randomized trial suggest that taurine supplementation may result in improvements in myotonic (slow relaxation after contraction of muscles) complaints. Well designed clinical trials are needed.
TENS: Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Electrodes are temporarily attached with paste in various patterns depending on the specific condition and treatment goals. Several studies have reported benefits of TENS therapy in patients with trigyminal neuralgia (facial pain). However, these trials have been small without clear descriptions of design or results. A small clinical study also found TENS effective in decreasing symptoms associated with spinal cord injury. Therefore, additional research is needed before a firm conclusion should be drawn in the area of neurological disorders.
Vitamin B6: Vitamin B6 (pyridoxine) is required for the synthesis of the neurotransmitters serotonin and norepinephrine, and for myelin formation. Pyridoxine deficiency in adults principally affects the peripheral nerves, skin, mucous membranes, and the blood cell system. In children, the central nervous system (CNS) is also affected. Major sources of vitamin B6 include: cereal grains, legumes, vegetables (carrots, spinach, peas), potatoes, milk, cheese, eggs, fish, liver, meat, and flour. Some prescription drugs called neuroleptics, which are used in psychiatric conditions, may cause movement disorders as an unwanted side effect. Vitamin B6 has been studied for the treatment of acute neuroleptic-induced akathisia (NIA, a neuromuscular disorder characterized by a feeling of "inner restlessness" or a constant urge to be moving) in schizophrenic and schizoaffective disorder patients. Preliminary results indicate that high doses of vitamin B6 may be useful additions to the available treatments for NIA, perhaps due to its combined effects on various neurotransmitter systems. Further research is needed to confirm these results.
Vitamin E:Vitamin E has been studied in the management of tardive dyskinesia (TD, a movement disorder characterized by persistent, repetitive (stereotypic) involuntary movements usually involving the lower face and mouth) and has been reported to significantly improve abnormal involuntary movements, although the results of existing studies are not conclusive enough to form a clear recommendation. Vitamin E may be more effective in higher doses and in people who have had TD for less than five years.
Other supplements that have unclear or conflicting scientific evidence include ashwagandha root (Withania somniferum), dehydroepiandosterone (DHEA), dong quai root (Angelica sinensis), homeopathic dilutions of belladonna (Belladonna atropa), choline, psychotherapy, selenium, and yohimbe bark (Pausinystalia yohimbe).
Historical or theoretical uses lacking sufficient evidence
Integrative therapies used in neurological disorders, such as Tourette's syndrome (TS), that have historical or theoretical uses but lack sufficient clinical evidence include: aloe (Aloe vera), arabinoxylan, aromatherapy, art therapy, asparagus (Asparagus officinalis ), arnica (Arnica montana), bacopa (Bacopa monnieri), bitter orange (Citrus aurantium), black cohosh (Actaea racemosa), cat's claw (Uncaria tomentosa), chelation therapy (EDTA), chondroitin sulfate, cordyceps (Cordyceps sinensis), devil's claw (Harpagophytum procumbens), horse chestnut (Aesculus hippocastanatum), kava kava (Piper methysticum), kudzu (Pueraria lobota), hypnosis, magnet therapy, lycopene, massage, muira puama (Ptychopetalum olacoides), omega-3 fatty acids, prayer, qi gong, relaxation, St. John's wort (Hypericum perforatum), and valerian (Valeriana sp.).
Diet: Nutritional changes along with the addition of supplements (vitamins, minerals, and herbs) may be effective in reducing symptoms associated with neurological disorders.
It is best to avoid caffeine and other stimulants, alcohol, and smoking.
It may be best to eliminate potential food allergens, including dairy (milk, cheese and sour cream), eggs, nuts, shellfish, wheat (gluten), corn, preservatives, and food additives (such as dyes and fillers).
Exercise: Maintaining physical fitness is important to those suffering from neurological conditions, such as Tourette's syndrome, as patients who exercise and keep active tend to do better with fewer symptoms and a slower disease progression than those who do not. A daily regimen of exercise can help the person feel better physically and mentally. Individuals should walk as much as possible, even if assistance is necessary. Talking with a healthcare provider about an exercise program is important.