Tics / Tourette Syndrome

DIAGNOSIS: Tics / Tourette Syndrome ICD-10: F95.2 (Tourette syndrome); F95.0 (Transient tic disorder); F95.1 (Chronic motor or vocal tic disorder); F95.8 (Other tic disorders); F95.9 (Tic disorder, unspecified) CPT CODES: 99213-99215 (outpatient E/M), 99281-99285 (ED E/M), 96116 (neuropsychological testing), 96132-96133 (neuropsychological testing by psychologist), 90834-90837 (psychotherapy for CBIT), 90846-90847 (family psychotherapy), 70553 (MRI brain with/without contrast), 95816 (EEG routine), 95819 (EEG with sleep), 85025 (CBC), 80048 (BMP), 84443 (TSH), 82390 (ceruloplasmin), 80061 (lipid panel), 80076 (hepatic panel), 80299 (therapeutic drug monitoring), 96127 (behavioral screening), 61863-61868 (DBS electrode placement), 95983 (DBS programming), 64616 (chemodenervation neck muscles), 64617 (chemodenervation larynx), J0585 (onabotulinumtoxinA per unit) SYNONYMS: Tourette syndrome, Tourette's syndrome, Tourette's disorder, Gilles de la Tourette syndrome, tic disorder, chronic tic disorder, motor tic disorder, vocal tic disorder, transient tic disorder, provisional tic disorder, complex tic disorder, tic spectrum disorder, coprolalia, echolalia, palilalia, phonic tics SCOPE: Diagnosis, severity assessment, and management of tic disorders including Tourette syndrome, chronic motor/vocal tic disorder, and provisional tic disorder. Covers Comprehensive Behavioral Intervention for Tics (CBIT), pharmacotherapy with alpha-2 agonists, antipsychotics, VMAT2 inhibitors, and botulinum toxin. Addresses common comorbidities (ADHD, OCD, anxiety, depression). Includes YGTSS scoring, DBS for medically refractory cases, and psychosocial support. Settings: ED (tic-related emergencies, severe exacerbations), HOSP (refractory cases, DBS), OPD (primary management setting).

VERSION: 1.1 CREATED: February 2, 2026 REVISED: February 2, 2026 STATUS: Approved

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PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════

1. LABORATORY WORKUP

1A. Essential/Core Labs

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC with differential (CPT 85025)	URGENT	ROUTINE	ROUTINE	-	Baseline before starting medications; exclude systemic illness	Normal
BMP (CPT 80048)	STAT	ROUTINE	ROUTINE	-	Electrolyte abnormalities; baseline renal function before medications	Normal
Hepatic panel (AST, ALT, Alk Phos, bilirubin, albumin) (CPT 80076)	URGENT	ROUTINE	ROUTINE	-	Baseline before antipsychotic or VMAT2 inhibitor therapy	Normal
TSH (CPT 84443)	URGENT	ROUTINE	ROUTINE	-	Hyperthyroidism can cause hyperkinetic movements mimicking tics	Normal (0.4-4.0 mIU/L)
Fasting glucose (CPT 82947)	-	ROUTINE	ROUTINE	-	Baseline metabolic screening before antipsychotic therapy	<100 mg/dL
Lipid panel (CPT 80061)	-	ROUTINE	ROUTINE	-	Baseline before antipsychotic therapy (metabolic syndrome risk)	Normal

1B. Extended Workup (Second-line)

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Ceruloplasmin (CPT 82390)	-	ROUTINE	ROUTINE	-	Wilson's disease screen if onset after age 10 or atypical features	>20 mg/dL (low suggests Wilson's)
ASO titer (CPT 86060)	-	ROUTINE	ROUTINE	-	PANDAS/PANS evaluation if abrupt tic onset with behavioral changes	Normal (elevated suggests recent streptococcal infection)
Anti-DNAse B (CPT 86215)	-	ROUTINE	ROUTINE	-	PANDAS/PANS evaluation; more specific for GAS infection	Normal
CRP (CPT 86140), ESR (CPT 85651)	-	ROUTINE	ROUTINE	-	Inflammatory markers if autoimmune/post-infectious etiology suspected	Normal
Ferritin (CPT 82728)	-	ROUTINE	ROUTINE	-	Iron deficiency can worsen tics and restless legs (common comorbidity)	>50 ng/mL preferred
Prolactin (CPT 84146)	-	ROUTINE	ROUTINE	-	Baseline before dopamine receptor blocking agents; monitor for hyperprolactinemia	Normal (male <15 ng/mL, female <25 ng/mL)
HbA1c (CPT 83036)	-	-	ROUTINE	-	Metabolic monitoring if on atypical antipsychotics	<5.7%
CYP2D6 genotyping (CPT 81226)	-	-	EXT	-	Pharmacogenomic guidance for tetrabenazine dosing (requires genotyping >50 mg/day)	Report metabolizer status

1C. Rare/Specialized (Refractory or Atypical)

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Serum copper (CPT 82525), 24-hour urine copper (CPT 82525)	-	-	EXT	-	Wilson's disease confirmation if ceruloplasmin low or borderline	Copper: 75-145 mcg/dL; urine <40 mcg/24hr
Anti-neuronal antibodies (NMDAR, LGI1, CASPR2) (CPT 86255)	-	EXT	EXT	-	Autoimmune encephalitis presenting with tics/movement disorder	Negative
Throat culture for Group A Streptococcus (CPT 87081)	-	ROUTINE	ROUTINE	-	Active streptococcal infection in PANDAS evaluation	Negative
Urine drug screen (CPT 80307)	URGENT	ROUTINE	-	-	Stimulant or substance use causing tics or exacerbation	Negative
Genetic testing for SLITRK1, HDC, CNTNAP2 (CPT 81479)	-	-	EXT	-	Rare monogenic tic disorders; research/family planning	No pathogenic variants
Comprehensive autoimmune panel (ANA, complement, anti-thyroid antibodies) (CPT 86235, 86200, 86376)	-	-	EXT	-	PANS workup with non-streptococcal autoimmune trigger	Negative

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2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI Brain without and with contrast (CPT 70553)	URGENT	ROUTINE	ROUTINE	-	Atypical tics; adult onset; focal neurological signs; to exclude structural/secondary causes	Normal; no basal ganglia or structural lesions	MRI-incompatible devices

2B. Extended

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
EEG routine (CPT 95816)	-	ROUTINE	ROUTINE	-	Differentiate tics from epileptic myoclonus or absence seizures	Normal; no epileptiform discharges	None
EEG with sleep (CPT 95819)	-	ROUTINE	ROUTINE	-	Suspected seizure disorder mimicking tics; tics with staring episodes	Normal background; no epileptiform discharges	None
Echocardiogram (CPT 93306)	-	ROUTINE	ROUTINE	-	Baseline before starting medications with QTc prolongation risk (pimozide, haloperidol)	Normal structure and function	None
ECG (CPT 93000)	-	ROUTINE	ROUTINE	-	Baseline QTc before antipsychotics (especially pimozide); cardiac screening	Normal sinus rhythm; QTc <450 msec	None

2C. Rare/Specialized

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI Brain with SWI/iron sequences (CPT 70553)	-	-	EXT	-	Suspected Wilson's disease or neurodegeneration with brain iron accumulation	No T2 hypointensity in basal ganglia	MRI contraindications
Slit lamp examination by ophthalmology (CPT 92012)	-	ROUTINE	ROUTINE	-	Wilson's disease evaluation; Kayser-Fleischer rings	No KF rings	None
Neuropsychological testing (CPT 96116, 96132)	-	-	ROUTINE	-	Formal assessment of ADHD, OCD, learning disabilities; pre-DBS evaluation	Characterize cognitive profile; guide treatment	None
Polysomnography (CPT 95810)	-	-	EXT	-	Sleep disturbance assessment; tics persisting in sleep; restless legs evaluation	Normal sleep architecture	None

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3. TREATMENT

3A. Behavioral Therapy (First-line)

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Comprehensive Behavioral Intervention for Tics (CBIT) (CPT 90834-90837)	In-person/telehealth	First-line for all tic disorders causing functional impairment; AAN Level A recommendation	8 sessions :: In-person :: weekly :: 8 sessions over 10 weeks; includes psychoeducation, habit reversal training (awareness training + competing response), relaxation techniques, and function-based assessment	Severe cognitive impairment preventing participation; active psychosis	YGTSS score at baseline and after completion; functional improvement; patient engagement	-	-	ROUTINE	-
Habit Reversal Training (HRT) (CPT 90834-90837)	In-person/telehealth	Core component of CBIT; delivered alone if full CBIT unavailable	8-12 sessions :: In-person :: weekly :: Awareness training for premonitory urge recognition; competing response training; social support	Severe cognitive impairment	YGTSS score; competing response use; tic frequency	-	-	ROUTINE	-
Exposure and Response Prevention (ERP) (CPT 90834-90837)	In-person/telehealth	Alternative behavioral approach for patients who tolerate premonitory urges poorly	8-12 sessions :: In-person :: weekly :: Graduated exposure to premonitory urge sensations with response prevention; habituation-based	Active psychosis; severe cognitive impairment	YGTSS score; premonitory urge rating (PUTS); tolerance of urges	-	-	ROUTINE	-

3B. First-line Pharmacotherapy (Alpha-2 Agonists)

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Guanfacine (Intuniv)	PO	First-line medication; preferred alpha-2 agonist for tics; also treats comorbid ADHD	1 mg :: PO :: qHS :: Start 1 mg qHS; increase by 1 mg q1wk; target 1-4 mg/day (divided BID for IR, daily for ER); max 4 mg/day	Second- or third-degree heart block; hypotension; concurrent use of strong CYP3A4 inhibitors	BP, HR at each visit; sedation; rebound hypertension if stopped abruptly; taper over 1 week to discontinue	-	ROUTINE	ROUTINE	-
Clonidine (Catapres)	PO	First-line medication; alpha-2 agonist for tics; also treats comorbid ADHD and insomnia	0.05 mg :: PO :: qHS :: Start 0.05 mg qHS; increase by 0.05 mg q3-7d; target 0.1-0.3 mg/day divided BID-QID; max 0.4 mg/day	Second- or third-degree heart block; severe hypotension	BP, HR at each visit; sedation, dry mouth; rebound hypertension if stopped abruptly; taper over 1-2 weeks	-	ROUTINE	ROUTINE	-
Clonidine transdermal patch (Catapres-TTS)	Transdermal	Alternative delivery; improved compliance; steady-state levels	0.1 mg/24hr :: Transdermal :: weekly :: Start 0.1 mg/24hr patch; increase by 0.1 mg q1-2wk; max 0.3 mg/24hr; change patch weekly	Second- or third-degree heart block; skin sensitivity at application site	BP, HR; skin irritation at application site; rotate placement sites	-	ROUTINE	ROUTINE	-

3C. Second-line Pharmacotherapy (Antipsychotics)

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Fluphenazine	PO	Second-line; typical antipsychotic with evidence for tic suppression	0.5 mg :: PO :: daily :: Start 0.5 mg daily; increase by 0.5 mg q1wk; target 1.5-5 mg/day; max 10 mg/day	Parkinsonism; CNS depression; comatose states; blood dyscrasias	Sedation; weight; EPS/tardive dyskinesia (AIMS q6mo); prolactin; QTc	-	ROUTINE	ROUTINE	-
Aripiprazole (Abilify)	PO	Second-line; atypical antipsychotic; favorable metabolic profile; AAN Level B	2 mg :: PO :: daily :: Start 2 mg daily; increase by 2.5-5 mg q1-2wk; target 2.5-15 mg/day; max 20 mg/day	Hypersensitivity; caution with strong CYP2D6/CYP3A4 inhibitors	Weight, BMI, waist circumference q3mo; fasting glucose, lipids q3-6mo; EPS/akathisia; prolactin baseline and PRN	-	ROUTINE	ROUTINE	-
Risperidone (Risperdal)	PO	Second-line; evidence from RCTs for tic reduction	0.25 mg :: PO :: qHS :: Start 0.25 mg qHS; increase by 0.25-0.5 mg q1wk; target 1-3 mg/day; max 4 mg/day	Hypersensitivity; caution in hepatic/renal impairment	Weight, BMI q3mo; fasting glucose, lipids q3-6mo; prolactin (gynecomastia risk); EPS; QTc	-	ROUTINE	ROUTINE	-
Haloperidol (Haldol)	PO	FDA-approved for Tourette syndrome; potent D2 antagonist; high EPS risk limits use	0.25 mg :: PO :: qHS :: Start 0.25 mg qHS; increase by 0.25-0.5 mg q1wk; target 1-4 mg/day; max 10 mg/day	Parkinsonism; QTc prolongation; CNS depression; comatose states	ECG at baseline and after dose changes; QTc (must be <500 msec); EPS/TD (AIMS q3-6mo); sedation; weight	-	ROUTINE	ROUTINE	-
Pimozide (Orap)	PO	FDA-approved for Tourette syndrome; reserved for refractory cases due to QTc risk	0.5 mg :: PO :: qHS :: Start 0.5 mg qHS; increase by 0.5-1 mg q1wk; target 2-4 mg/day; max 10 mg/day (0.2 mg/kg/day in children); CYP2D6 genotyping recommended at doses >4 mg	QTc >440 msec (males) or >450 msec (females); congenital long QT; concurrent QTc-prolonging drugs; strong CYP3A4/CYP2D6 inhibitors; hypokalemia	ECG at baseline, each dose increase, and q6mo; QTc must remain <470 msec; EPS/TD (AIMS q3-6mo); CYP2D6 genotyping; weight; sedation	-	ROUTINE	ROUTINE	-
Ziprasidone (Geodon)	PO	Alternative atypical antipsychotic; lower weight gain but QTc risk	5 mg :: PO :: daily :: Start 5 mg daily; increase by 5-10 mg q1wk; target 5-40 mg/day; take with food (>500 kcal for absorption)	QTc prolongation; concurrent QTc-prolonging drugs; recent MI; uncompensated heart failure	ECG at baseline; QTc monitoring; weight, fasting glucose, lipids q3-6mo; EPS	-	ROUTINE	ROUTINE	-

3D. Third-line Pharmacotherapy (VMAT2 Inhibitors and Others)

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Tetrabenazine (Xenazine)	PO	VMAT2 inhibitor; third-line for moderate-severe tics refractory to first/second-line agents	12.5 mg :: PO :: daily :: Start 12.5 mg daily; increase by 12.5 mg q1wk; target 25-75 mg/day divided BID-TID; max 200 mg/day; CYP2D6 genotyping required at doses >50 mg/day	Depression/suicidality (Black Box); MAO-I use; hepatic impairment; reserpine use within 20 days	Depression screening (PHQ-9) at each visit; suicidality assessment; parkinsonism; akathisia; sedation; CYP2D6 genotyping	-	-	ROUTINE	-
Deutetrabenazine (Austedo)	PO	VMAT2 inhibitor; better tolerated than tetrabenazine; longer half-life	6 mg :: PO :: daily :: Start 6 mg daily; increase by 6 mg/day weekly; target 12-48 mg/day divided BID; max 48 mg/day; take with food	Depression/suicidality (Black Box); MAO-I use; hepatic impairment; reserpine use within 20 days	Depression screening (PHQ-9) at each visit; suicidality assessment; parkinsonism; akathisia; QTc at baseline and dose changes	-	-	ROUTINE	-
Valbenazine (Ingrezza)	PO	VMAT2 inhibitor; once-daily dosing; off-label for refractory tics	40 mg :: PO :: daily :: Start 40 mg once daily; increase to 80 mg daily after 1 week if tolerated; max 80 mg/day	Congenital long QT; strong CYP2D6 inhibitors at higher dose; severe hepatic impairment	QTc at baseline and after dose increase; somnolence; depression; parkinsonism	-	-	ROUTINE	-
Topiramate (Topamax)	PO	Adjunctive therapy; reduces tic severity; also treats comorbid migraine	25 mg :: PO :: qHS :: Start 25 mg qHS; increase by 25 mg q1-2wk; target 50-200 mg/day divided BID; max 200 mg/day	Metabolic acidosis; kidney stones; acute myopia/angle-closure glaucoma	Bicarbonate level; renal function; cognitive effects (word-finding difficulty); weight; kidney stones	-	-	ROUTINE	-
Clonazepam	PO	Adjunct for tic suppression; also treats comorbid anxiety	0.25 mg :: PO :: qHS :: Start 0.25 mg qHS; increase by 0.25 mg q3-7d; target 0.5-2 mg/day divided BID; max 4 mg/day	Severe respiratory depression; severe hepatic impairment; substance abuse history	Sedation; dependence risk; falls; taper slowly if discontinuing (do not stop abruptly)	-	ROUTINE	ROUTINE	-
Baclofen	PO	Adjunct for tic suppression	5 mg :: PO :: TID :: Start 5 mg TID; increase by 5 mg/dose q3-5d; target 30-60 mg/day divided TID; max 80 mg/day	Severe renal impairment (dose adjust); abrupt withdrawal risk	Sedation; weakness; taper slowly if discontinuing	-	-	ROUTINE	-

3E. Targeted/Focal Therapy

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
OnabotulinumtoxinA (Botox) - cervical tics (CPT 64616, J0585)	IM	Focal motor tics causing pain or disability (cervical, facial); phonic tics (vocal cord injection)	25-100 units :: IM :: q12wk :: Inject affected muscles; cervical tics 25-100 units divided; facial tics 5-25 units per site; repeat q12wk; EMG guidance for small muscles	Infection at site; myasthenia gravis; ALS	Dysphagia (if neck muscles); local weakness; antibody formation with repeated use	-	-	ROUTINE	-
OnabotulinumtoxinA (Botox) - phonic/vocal tics (CPT 64617, J0585)	IM (laryngeal)	Disabling vocal tics (coprolalia, loud vocalizations); refractory to systemic therapy	1.25-2.5 units :: IM :: q12wk :: 1.25-2.5 units per vocal cord via EMG-guided injection; repeat q12wk; specialist procedure	Infection at site; myasthenia gravis; ALS; vocal cord paralysis	Breathy voice; dysphagia; periodic indirect laryngoscopy	-	-	ROUTINE	-

3F. Comorbidity-Specific Treatment

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Methylphenidate (Ritalin, Concerta)	PO	ADHD comorbidity; does NOT worsen tics (AAN Level A evidence)	5 mg :: PO :: BID :: Start 5 mg BID (IR) or 18 mg daily (ER); increase by 5-10 mg/wk; target 20-60 mg/day; max 72 mg/day (ER)	Concurrent MAO-I use; pheochromocytoma; severe anxiety; glaucoma	HR, BP; appetite/weight; sleep; tic severity (monitor but stimulants generally safe)	-	ROUTINE	ROUTINE	-
Amphetamine/dextroamphetamine (Adderall)	PO	ADHD comorbidity; alternative stimulant	5 mg :: PO :: daily :: Start 5 mg daily (IR) or 10 mg daily (XR); increase by 5-10 mg/wk; target 10-30 mg/day; max 40 mg/day	Concurrent MAO-I use; pheochromocytoma; severe cardiac disease; glaucoma	HR, BP; appetite/weight; sleep; tic severity; cardiac screening if risk factors	-	ROUTINE	ROUTINE	-
Atomoxetine (Strattera)	PO	ADHD comorbidity; non-stimulant; improves both ADHD and tics	0.5 mg/kg :: PO :: daily :: Start 0.5 mg/kg/day; increase to 1.2 mg/kg/day after 3-7 days; max 1.4 mg/kg/day or 100 mg/day	Concurrent MAO-I use; narrow-angle glaucoma; pheochromocytoma; severe cardiac disease	BP, HR; suicidality (Black Box in children); hepatotoxicity (rare); appetite/weight	-	ROUTINE	ROUTINE	-
Fluoxetine (Prozac)	PO	OCD comorbidity (first-line SSRI for OCD in Tourette)	10 mg :: PO :: daily :: Start 10 mg daily; increase by 10 mg q2-4wk; target 20-60 mg/day for OCD; max 80 mg/day	Concurrent MAO-I use; concurrent pimozide (QTc); concurrent thioridazine	Suicidality (Black Box in children); activation/mania; serotonin syndrome; OCD severity (Y-BOCS)	-	ROUTINE	ROUTINE	-
Sertraline (Zoloft)	PO	OCD comorbidity; alternative SSRI	25 mg :: PO :: daily :: Start 25 mg daily; increase by 25-50 mg q1-2wk; target 50-200 mg/day for OCD; max 200 mg/day	Concurrent MAO-I use; concurrent pimozide	Suicidality (Black Box in children); activation; GI side effects; serotonin syndrome	-	ROUTINE	ROUTINE	-
Cognitive Behavioral Therapy (CBT) with ERP (CPT 90834-90837)	In-person	OCD comorbidity; first-line behavioral intervention for OCD symptoms	12-20 sessions :: In-person :: weekly :: Exposure and response prevention protocol targeting OCD symptoms; run concurrently with CBIT for tics	Active psychosis; severe cognitive impairment	Y-BOCS score at baseline and q4wk; functional improvement	-	-	ROUTINE	-

3G. Disease-Modifying/Surgical Therapy

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Deep brain stimulation (GPi or CM-Pf thalamus) (CPT 61863-61868, 95983)	Surgical	Severe, medication-refractory Tourette syndrome causing significant disability; YGTSS total tic score >35 despite adequate trials	Bilateral stimulation :: Surgical :: per protocol :: Bilateral electrode placement (GPi, centromedian-parafascicular complex of thalamus, or anterior limb of internal capsule); programming over months; full effect may take 3-12 months	MRI; neuropsychological testing; multidisciplinary evaluation; psychiatric stability confirmed; age >18-25 (brain maturation); failed CBIT + adequate trials of 3+ medication classes	Active psychosis; coagulopathy; active infection; unrealistic expectations; age <18 (relative, emerging evidence); medically unstable	Programming optimization q1-3mo initially; YGTSS reassessment; battery replacement q3-5yr; psychiatric monitoring; speech/swallowing	-	-	ROUTINE	-

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4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation	ED	HOSP	OPD	ICU
Movement disorders neurology for diagnosis confirmation, YGTSS scoring, treatment planning, and medication management	-	ROUTINE	ROUTINE	-
Behavioral therapist experienced in CBIT/HRT for tic disorders (first-line treatment referral)	-	-	ROUTINE	-
Psychiatry for comorbid ADHD, OCD, anxiety, depression, or rage attacks; medication co-management	-	ROUTINE	ROUTINE	-
Neuropsychological testing for formal ADHD assessment, learning disability evaluation, and cognitive baseline	-	-	ROUTINE	-
Neurosurgery consultation for DBS evaluation if medication-refractory (typically after failure of CBIT + 3 medication classes)	-	-	ROUTINE	-
Speech therapy if vocal tics significantly impair communication or cause vocal cord strain	-	-	ROUTINE	-
School liaison/504 plan or IEP coordination for academic accommodations (extended time, separate testing, tic breaks)	-	-	ROUTINE	-
Ophthalmology if eye-blinking tics persist or visual symptoms present (rule out ophthalmologic causes)	-	-	ROUTINE	-
Psychology/counseling for coping strategies, self-esteem, bullying management, and family psychoeducation	-	-	ROUTINE	-
Genetics counseling if family history significant or rare genetic tic disorder suspected (SLITRK1, HDC)	-	-	ROUTINE	-

4B. Patient Instructions

Recommendation	ED	HOSP	OPD
Tics are involuntary; do not ask the patient to suppress tics or punish tic behaviors as this worsens anxiety and tics	ROUTINE	ROUTINE	ROUTINE
Tics naturally wax and wane; periods of increased tics do not necessarily mean treatment failure	-	ROUTINE	ROUTINE
Many patients experience improvement in late adolescence/early adulthood; approximately one-third have significant tic reduction by adulthood	-	-	ROUTINE
CBIT is the first-line treatment and should be tried before or alongside medications; it teaches skills to manage tics	-	-	ROUTINE
Report new involuntary movements, stiffness, or tremor that could indicate medication side effects (EPS/parkinsonism)	-	ROUTINE	ROUTINE
Report mood changes, depression, or suicidal thoughts especially if on VMAT2 inhibitors or antipsychotics	URGENT	ROUTINE	ROUTINE
Return to ED if sudden severe tic exacerbation with self-injurious behavior, breathing difficulty from vocal tics, or inability to eat/drink	STAT	ROUTINE	ROUTINE
Stimulant medications for ADHD are safe with tics and do not need to be discontinued; discuss with your neurologist before stopping	-	ROUTINE	ROUTINE
Keep a tic diary noting triggers (stress, fatigue, excitement), premonitory urges, and response to treatment	-	-	ROUTINE
Educate teachers, coaches, and family members about tic disorders to reduce stigma and promote supportive environments	-	-	ROUTINE

4C. Lifestyle & Prevention

Recommendation	ED	HOSP	OPD
Stress management techniques (mindfulness, deep breathing, progressive muscle relaxation) as stress is the most common tic exacerbator	-	ROUTINE	ROUTINE
Adequate sleep (age-appropriate: 8-10 hours for adolescents, 7-9 for adults) as fatigue worsens tics	-	ROUTINE	ROUTINE
Regular aerobic exercise (30+ minutes most days) to reduce tic severity and improve comorbid ADHD/anxiety	-	-	ROUTINE
Limit caffeine and energy drinks which exacerbate tics, anxiety, and insomnia	-	ROUTINE	ROUTINE
Activities requiring focused attention (music, sports, art) reduce tics through directed concentration	-	-	ROUTINE
Peer support groups (Tourette Association of America, local support groups) for patients and families	-	-	ROUTINE
Anti-bullying strategies and school education programs; tic disorders are covered under Section 504 and IDEA	-	-	ROUTINE
Identify and avoid triggers where possible (certain situations, foods, sleep deprivation)	-	-	ROUTINE
Moderate screen time; excessive screen time exacerbates tics in some patients	-	-	ROUTINE

═══════════════════════════════════════════════════════════════ SECTION B: REFERENCE ═══════════════════════════════════════════════════════════════

5. DIFFERENTIAL DIAGNOSIS

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Functional (psychogenic) tic disorder	Sudden onset in adulthood; inconsistent; distractible; non-suppressible; no premonitory urge; atypical movements	Clinical observation; Berardelli criteria; psychiatric evaluation; resolution with distraction
Myoclonus	Brief shock-like jerks; no premonitory urge; not suppressible; may have cortical or subcortical origin	EEG (cortical myoclonus has time-locked EEG correlate); EMG (burst duration <100 ms vs. tics >100 ms)
Chorea (Sydenham, Huntington, other)	Continuous flow of random movements; dance-like; no premonitory urge; not suppressible	ASO titer (Sydenham); genetic testing (Huntington); MRI; clinical pattern
Stereotypies	Rhythmic, repetitive, patterned movements; onset before age 3; associated with ASD; not preceded by urge; pleasant/soothing	Clinical history (onset, pattern, context); ASD evaluation; no waxing/waning
OCD-related compulsions	Driven by anxiety rather than premonitory urge; purposeful complex behaviors; ego-dystonic	Clinical assessment; Y-BOCS; driven by specific obsessions rather than sensory urge
Epileptic myoclonus or absence seizures	Time-locked EEG correlate; no premonitory urge; no suppressibility; impaired awareness (absence)	EEG (epileptiform discharges); video-EEG monitoring
Drug-induced movement disorder (akathisia, tardive)	Temporal relationship with dopamine blockers or stimulants; akathisia = inner restlessness; tardive = choreiform	Medication history; AIMS assessment; resolution with drug withdrawal (akathisia)
Wilson's disease	Hepatic dysfunction; Kayser-Fleischer rings; onset age 5-40; multiple movement disorder types	Ceruloplasmin (low); slit lamp exam; 24h urine copper; ATP7B testing
PANDAS/PANS	Abrupt, dramatic onset of tics/OCD; prepubertal; temporal relationship to streptococcal infection; neuropsychiatric symptoms	ASO titer; anti-DNAse B; throat culture; clinical criteria (acute onset + neuropsychiatric symptoms)
Dystonia	Sustained or intermittent muscle contraction causing abnormal postures; no suppressibility; no premonitory urge	Clinical pattern (sustained vs. brief); EMG (co-contraction pattern); DaTscan if needed
Hemifacial spasm	Unilateral; synchronous contraction of facial muscles; persists in sleep; caused by vascular compression	MRI/MRA (vascular loop compressing CN VII); EMG (lateral spread response)
Habit disorder / mannerism	Purposeful repetitive behavior; fully voluntary; no urge; associated with boredom or anxiety	Clinical history; behavioral assessment; resolution with redirection
Restless legs syndrome	Urge to move legs (not face/neck); worse at rest/evening; relieved by movement; no vocalizations	Clinical criteria (IRLSSG); ferritin level; polysomnography

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6. MONITORING PARAMETERS

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
YGTSS (Yale Global Tic Severity Scale) total score	Baseline; q3mo on treatment; each medication change	25%+ improvement; total tic score <15 for mild; goal is functional improvement	Adjust treatment; add CBIT if not started; escalate pharmacotherapy; refer for DBS if >35 despite treatment	-	ROUTINE	ROUTINE	-
Premonitory Urge for Tics Scale (PUTS)	Baseline; q6mo	Improvement or stable	Guide CBIT approach; if high urge-tic correlation, CBIT is more effective	-	-	ROUTINE	-
Comorbidity screening (ADHD, OCD, anxiety, depression)	Each visit	Y-BOCS <16 (OCD); PHQ-9 <10; GAD-7 <10; ASRS for ADHD	Adjust comorbidity treatment; add behavioral therapy; psychiatric referral	-	ROUTINE	ROUTINE	-
Weight, BMI, waist circumference (on antipsychotics)	Baseline, monthly x3mo, then q3mo	Weight gain <7% from baseline	Dietary counseling; switch to lower metabolic risk agent; metformin if needed	-	ROUTINE	ROUTINE	-
Fasting glucose, HbA1c, lipid panel (on antipsychotics)	Baseline, 3mo, then q6-12mo	Glucose <100; HbA1c <5.7%; LDL <130	Switch agent; dietary modification; endocrine referral if diabetes develops	-	ROUTINE	ROUTINE	-
ECG / QTc interval (on pimozide, haloperidol, ziprasidone)	Baseline, each dose increase, q6-12mo	QTc <470 msec (must be <500 msec absolute)	Reduce dose; discontinue if >500 msec; electrolyte correction; switch agent	-	ROUTINE	ROUTINE	-
AIMS assessment (on antipsychotics)	Baseline, then q6mo	No involuntary movements	Reduce antipsychotic dose; switch to VMAT2 inhibitor; diagnose TD if score >2 in 2 areas	-	ROUTINE	ROUTINE	-
Prolactin (on risperidone, haloperidol, pimozide)	Baseline, 3mo, then PRN for symptoms	Male <15 ng/mL; female <25 ng/mL	Reduce dose; switch to prolactin-sparing agent (aripiprazole); endocrine referral if symptomatic	-	ROUTINE	ROUTINE	-
Depression/suicidality screening (on VMAT2 inhibitors)	Each visit	No suicidal ideation; PHQ-9 <10	Discontinue VMAT2 inhibitor; immediate psychiatric referral; safety planning	-	ROUTINE	ROUTINE	-
BP and HR (on alpha-2 agonists)	Each visit; more frequently during titration	SBP >90; HR >50; no symptomatic hypotension	Reduce dose; hold if symptomatic; do not stop abruptly (taper over 1-2 weeks)	-	ROUTINE	ROUTINE	-
DBS parameters and battery (post-DBS)	q1-3mo initially, then q6-12mo	Optimal tic control; battery >30%	Reprogram; schedule battery replacement if needed	-	-	ROUTINE	-
Functional assessment (school/work performance, social participation, QoL)	Each visit	Improved or stable ADLs, academic/occupational function	Adjust treatment; add CBIT; school accommodations; vocational support	-	ROUTINE	ROUTINE	-

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7. DISPOSITION CRITERIA

Disposition	Criteria
Discharge home	Mild-moderate tics without self-injury; diagnosis confirmed; treatment plan initiated; outpatient follow-up scheduled
Admit to floor	Severe self-injurious tics (tic-related head banging, neck injury); inability to eat or drink due to tics; severe tic exacerbation requiring medication adjustment under observation; new-onset malignant Tourette variant
Admit to ICU	Respiratory compromise from vocal tics or cervical tics; rhabdomyolysis from severe motor tics; tic-related self-injurious behavior causing significant trauma; severe medication adverse effects (NMS, cardiac arrhythmia)
Transfer to higher level	DBS programming issues requiring specialized movement disorders center; refractory malignant Tourette requiring tertiary center expertise
Outpatient follow-up	2-4 weeks after new medication started; q3mo when stable on medication; 2 weeks after CBIT initiation; 6-12 months when tics well-controlled; more frequent if comorbidities being actively managed

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8. EVIDENCE & REFERENCES

Recommendation	Evidence Level	Source
CBIT is first-line treatment for tics in children and adults	Class I, Level A	Pringsheim T et al. Neurology 2019 (AAN Practice Guideline)
CBIT is effective and durable for tic reduction (CBIT randomized trial)	Class I, Level A	Piacentini J et al. JAMA 2010
Alpha-2 agonists (guanfacine, clonidine) recommended for tics, especially with comorbid ADHD	Class I, Level B	Pringsheim T et al. Neurology 2019 (AAN Guideline)
Haloperidol and pimozide FDA-approved for Tourette syndrome tic suppression	Class I, Level A	Shapiro AK et al. Arch Gen Psychiatry 1989
Aripiprazole effective for tic reduction in Tourette syndrome	Class I, Level B	Yoo HK et al. JAMA 2013
Risperidone effective for tic reduction in randomized trials	Class I, Level B	Dion Y et al. J Clin Psychopharmacol 2002
Fluphenazine effective for tic suppression	Class II, Level B	Borison RL et al. J Clin Psychopharmacol 1983
Stimulant medications do not worsen tics in most patients	Class I, Level A	Pringsheim T et al. Neurology 2019 (AAN Guideline)
YGTSS is the gold standard for tic severity assessment	Expert consensus	Leckman JF et al. J Am Acad Child Adolesc Psychiatry 1989
DBS (GPi/CM-Pf) for refractory Tourette syndrome	Class II-III, Level C	Martinez-Ramirez D et al. Brain Stimul 2018
Botulinum toxin for focal motor and phonic tics	Class II, Level B	Marras C et al. Mov Disord 2001
Tetrabenazine for hyperkinetic movement disorders including tics	Class II, Level B	Jankovic J, Beach J. Neurology 1997
Topiramate for tic reduction	Class II, Level B	Jankovic J et al. Neurology 2010
PANDAS/PANS clinical criteria and management	Expert consensus	Swedo SE et al. Pediatrics 1998
European guidelines on Tourette syndrome assessment and treatment	Expert consensus	Roessner V et al. Eur Child Adolesc Psychiatry 2011
AAN guideline on treatment of tics in people with Tourette syndrome and chronic tic disorders	Expert consensus, Level A-C	Pringsheim T et al. Neurology 2019
Natural history of Tourette syndrome (waxing/waning, adolescent peak, adult improvement)	Class II, Level B	Bloch MH et al. Lancet 2006

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CHANGE LOG

v1.1 (February 2, 2026) - Replaced ## SECTION A/B headers and --- dividers with standard ═══ section dividers per approved plan format - Added REVISED date field to metadata block - Updated VERSION to 1.1; STATUS to "Revised per checker v1.1" - Fixed weak/suggestive language: "may reduce" changed to directive in topiramate and baclofen indications (Section 3D) - Fixed weak language: "may benefit from" changed to directive in ERP indication (Section 3A) - Fixed weak language: "may improve both" changed to "improves both" for atomoxetine (Section 3F) - Fixed weak language: "can be delivered alone" changed to "delivered alone" for HRT (Section 3A) - Fixed weak language: "can run concurrently" changed to "run concurrently" for CBT with ERP (Section 3F) - Fixed weak language: "may exacerbate" changed to "exacerbate" in lifestyle recommendations (Section 4C) - Fixed weak language: "often reduce tics" changed to "reduce tics" in lifestyle recommendations (Section 4C) - Fixed weak language: "may be more effective" changed to "is more effective" for PUTS monitoring (Section 6) - Fixed suggestive language: "consider DBS referral" changed to "refer for DBS" in YGTSS monitoring (Section 6) - Fixed suggestive language: "consider TD diagnosis" changed to "diagnose TD" in AIMS monitoring (Section 6) - Fixed weak language: "Avoid trigger identification and avoidance" rephrased to "Identify and avoid triggers" (Section 4C) - Fixed weak language: "Screen time moderation" rephrased to "Moderate screen time" with directive phrasing (Section 4C) - Maintained all existing clinical content, medication dosing, and evidence references

v1.0 (February 2, 2026) - Initial template creation - Comprehensive coverage of tic disorders (Tourette syndrome, chronic motor/vocal tic disorder, provisional tic disorder) - Behavioral therapy section (CBIT, HRT, ERP) as first-line treatment per AAN 2019 guideline - Alpha-2 agonist pharmacotherapy (guanfacine, clonidine) as first-line medication - Antipsychotic options (aripiprazole, risperidone, haloperidol, pimozide, fluphenazine, ziprasidone) - VMAT2 inhibitor coverage (tetrabenazine, deutetrabenazine, valbenazine) - Botulinum toxin for focal motor and phonic tics - Comorbidity-specific treatment (ADHD: stimulants, atomoxetine; OCD: SSRIs, CBT) - PANDAS/PANS evaluation in laboratory workup - DBS for medically refractory Tourette syndrome - YGTSS scoring and monitoring parameters - Metabolic monitoring protocol for antipsychotic-treated patients - Structured dosing format for order sentence generation

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APPENDIX A: YGTSS (YALE GLOBAL TIC SEVERITY SCALE) SCORING

Motor Tic Rating

Domain	Score Range	Description
Number	0-5	Count of distinct motor tics
Frequency	0-5	How often motor tics occur (0 = none, 5 = always present)
Intensity	0-5	Forcefulness of motor tics
Complexity	0-5	Simple vs. complex, purposeful-appearing
Interference	0-5	Degree tics interfere with ongoing behavior
Motor Total	0-25	Sum of 5 domains

Vocal/Phonic Tic Rating

Domain	Score Range	Description
Number	0-5	Count of distinct vocal tics
Frequency	0-5	How often vocal tics occur
Intensity	0-5	Volume and forcefulness
Complexity	0-5	Simple vs. complex vocalizations
Interference	0-5	Degree tics interfere with speech/communication
Vocal Total	0-25	Sum of 5 domains

Overall Impairment

Score	Severity
0	No impairment
10	Minimal impairment
20	Mild impairment
30	Moderate impairment
40	Marked impairment
50	Severe impairment

Total YGTSS Score Interpretation

Component	Range	Notes
Total Tic Score	0-50	Motor total + Vocal total
Impairment Score	0-50	Single global impairment rating
Global Severity Score	0-100	Total Tic Score + Impairment Score

Severity	Total Tic Score	Clinical Interpretation
None	0	No tics
Minimal	1-9	Barely noticeable tics
Mild	10-19	Noticeable but not disruptive
Moderate	20-29	Clearly present; some functional impact
Marked	30-39	Prominent tics; significant impairment
Severe	40-50	Near-constant severe tics; major disability

APPENDIX B: TOURETTE SYNDROME DIAGNOSTIC CRITERIA (DSM-5)

Tourette Syndrome (F95.2)

Criterion	Requirement
A	Both multiple motor tics AND one or more vocal (phonic) tics have been present at some time during illness, although not necessarily concurrently
B	Tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset
C	Onset is before age 18 years
D	The disturbance is not attributable to the physiological effects of a substance or another medical condition

Persistent (Chronic) Motor or Vocal Tic Disorder (F95.1)

Criterion	Requirement
A	Single or multiple motor tics OR vocal tics have been present during the illness, but not both motor and vocal
B	Tics have persisted for more than 1 year since first tic onset
C	Onset is before age 18 years
D	Not attributable to substance or medical condition
E	Criteria for Tourette syndrome have never been met

Provisional Tic Disorder (F95.0)

Criterion	Requirement
A	Single or multiple motor and/or vocal tics
B	Tics have been present for less than 1 year since first tic onset
C	Onset is before age 18 years
D	Not attributable to substance or medical condition
E	Criteria for Tourette syndrome or persistent tic disorder have never been met

APPENDIX C: COMMON COMORBIDITIES AND PREVALENCE

Comorbidity	Prevalence in Tourette	Clinical Notes
ADHD	50-60%	Most common comorbidity; treat with stimulants or alpha-2 agonists (guanfacine preferred for dual benefit); stimulants do NOT worsen tics per AAN guideline
OCD	30-50%	Second most common; often "just right" phenomena rather than contamination fears; SSRIs + CBT with ERP; avoid clomipramine with pimozide
Anxiety disorders (GAD, social anxiety)	30-40%	Worsens tics through stress; CBT; SSRIs; guanfacine helps both tics and anxiety
Depression	20-25%	Screen regularly especially on VMAT2 inhibitors/antipsychotics; SSRIs; CBT; often reactive to chronic tic burden
Rage attacks / explosive outbursts	25-70%	Often most disabling feature; often more impairing than tics; behavioral strategies; mood stabilizers in severe cases
Learning disabilities	20-30%	Neuropsychological testing; IEP/504 plan; educational accommodations
Sleep disorders	25-50%	Insomnia, restless legs, sleep-disordered breathing; sleep hygiene; clonidine helps both tics and insomnia
Self-injurious behavior	14-33%	Head banging, hitting self, eye poking; requires hospitalization if severe; urgent medication optimization
Autism spectrum disorder	5-10%	Distinguished from stereotypies by premonitory urge, waxing/waning pattern, suppressibility