MKSAP Quiz: 2-year history of repetitive movements
An 18-year-old woman is evaluated for a 2-year history of repetitive fast movements of the neck that tilt the head to the right side. She reports that these movements are preceded by a feeling of discomfort in the right shoulder and that if she concentrates and taps the right foot immediately after this sensory cue, she usually can avoid the neck movements. Following a physical exam, what is the most appropriate treatment?
An 18-year-old woman is evaluated for a 2-year history of repetitive fast movements of the neck that tilt the head to the right side. She reports that these movements are preceded by a feeling of discomfort in the right shoulder and that if she concentrates and taps the right foot immediately after this sensory cue, she usually can avoid the neck movements. She is a senior in high school and says she has not been able to use this method successfully in the classroom, especially during examinations, when she often experiences a cluster of movements that exhaust and distract her. Her mother notes that before onset of the neck symptoms, the patient used to roll her eyes and clear her throat frequently. She has obsessive-compulsive disorder treated with sertraline.
On physical examination, vital signs are normal. During the examination, the patient displays rapid tilting movements of the head followed by rolling of the head and shoulder; these movements repeat several times in a stereotyped manner. The patient can suppress these movements on request.
Which of the following is the most appropriate treatment?
A. Botulinum toxin injection
B. Clonidine administration
C. Cognitive behavioral therapy
D. Haloperidol administration
MKSAP Answer and Critique
The correct answer is B. Clonidine administration. This content is available to MKSAP 18 subscribers as Question 30 in the Neurology section. More information about MKSAP is available online. −source=google&utm−medium=wid&utm−campaign=mksapques
This patient should be treated with clonidine. The suppressible stereotyped neck movements and premonitory sensory cues are consistent with motor tics, and the history of other motor (eye rolling) and vocal (throat clearing) tics, childhood onset, duration of greater than 1 year, and comorbidity of obsessive-compulsive disorder (OCD) are consistent with the diagnosis of Tourette syndrome. Clonidine is a first-line agent used to treat Tourette syndrome. Anti-tic medications should be considered when tics interfere with education, daily function, or work. Other first-line medications include guanfacine, topiramate, and the dopamine-depleter agent tetrabenazine. Second-line treatments include antipsychotic agents (such as haloperidol), but their benefit should be weighed against risk of tardive dyskinesia.
Although botulinum toxin can be considered as an off-label option in the treatment of severe refractory cervical tics, this patient has not yet tried medication to control her tics. Botulinum toxin also is indicated in the treatment of cervical dystonia, but this disorder is not consistent with her clinical findings of suppressibility and the absence of sustained motor activity.
Treatment of mild tics includes reassurance, treatment of psychiatric comorbidities (such as the sertraline she already takes for OCD), and cognitive behavioral therapy to teach patients about tic diversion techniques (such as the foot taps she initiates after sensory premonitory cues). Given that this patient's symptoms have persisted, pharmacologic therapy for Tourette syndrome is appropriate.
Haloperidol should not be considered before a trial of first-line anti-tic medications is attempted. Clonidine appears to be better tolerated than antidopaminergic drugs, such as haloperidol or risperidone. Additionally, the tardive dyskinesia that can result from neuroleptic agents may take months to years to resolve after discontinuation of the culprit drug.
Key Point
- First-line agents used to treat Tourette syndrome when the associated tics interfere with education, daily function, or work are clonidine, guanfacine, topiramate, and tetrabenazine.