By: Clara O’Hara
What is Tourette Syndrome?
According to the National Institute of Health, Tourette syndrome is a neurological disorder characterized by sudden, repetitive, rapid, and unwanted movements or vocal sounds, also known as tics. There are two types of tics; motor and vocal, which can be simple or complex.
Signs and Symptoms:
The first signs and symptoms of Tourette syndrome are tics. Simple tics are brief and involve a limited number of muscle groups whereas complex tics are more coordinated patterns and involve several muscle groups (NIH, 2021).
According to the National Institute of Health, the following listed below are examples of motor and vocal tics someone with Tourette syndrome can experience:
Motor Tics:
Simple: Eye blinking, facial grimacing, shoulder shrugging, head jerking, and shoulder jerking.
Complex: Facial grimacing combined with a head twist and a shoulder shrug. May appear purposeful including sniffing or touching objects, hopping, jumping, bending, twisting.
Vocal Tics:
Simple: Repetitive throat clearing, sniffing, barking, or grunting sounds
Complex: Repeat words/phrases, repeat others’ words/phrases (echolalia), use vulgar, obscene language/swear words (coprolalia).
Tourette syndrome and Epilepsy
Among children with Tourette syndrome, there are studies suggesting epilepsy often develops at higher rates with this disorder. Children with Tourette syndrome are more likely than the general population to develop epilepsy, with four percent of children with new-onset Tourette syndrome developing epilepsy in the following years (Wong et. al., 2016). Children with epilepsy, especially intractable epilepsy are likely to develop Tourette syndrome (Hung, 2017). Studies also disclosed that medication of Tourette syndrome such as haloperidol, risperidone, sulpiride, clonidine, and aripiprazole would not cause an increased risk of epilepsy. Tourette syndrome and epilepsy share similar neurobiology. The abnormal cortico-basal ganglia circuit connections and dopaminergic systems are possibly involved. Alternations of dopaminergic neurotransmission and corticostriatal network are substantially evident in Tourette syndrome. Modulation of autonomic activity linkage to cognition and behavior was demonstrated in the central thalamocortical regulation. This further gives reason to the correlation in the study existing between epilepsy and Tourette syndrome.
Diagnosis
Medical professional often diagnose epilepsy as Tourette syndrome or speech disorders and diagnose Tourette syndrome or speech disorders with epilepsy (Papadopoulou et. al., 2022). Simple tics may be mistaken for myoclonic epilepsy whilst complex tics may be mistaken for complex partial seizures (Richards, 1995). It is important to know the difference between the conditions for healthcare professionals and parents as some cases of misdiagnosis may result in harming (Hosier and McKelvey, 2014) or the death of an individual (Richards, 1995).
There is no specific test that can treat Tourette syndrome (Mayo Clinic, 2023). The diagnosis is based on the history of your signs and symptoms. The criteria used for diagnosing Tourette syndrome includes:
Both motor tics and vocal tics are present, although not necessarily at the same time.
Tics occur several times a day, nearly every day or intermittently, for more than a year
Tics begin before age eighteen
Tics are not caused by medication, other substances, or another medical condition
Tics must change over time in location, frequency, type, complexity, or severity
Treatment
Some medications that may be safe for someone with epilepsy and Tourette syndrome are levetiracetam and topiramate. Levetiracetam, also known as Keppra, has shown improvements in occurrence of tics, behavior, and school performance for children with Tourette syndrome (Awaad, 2006). Children with epilepsy, especially children under the age of two, benefitted from levetiracetam through reduction or being free from seizures (Krief et. al., 2008). Efficacy has been the highest among children with general epilepsy. Furthermore, studies showing treatment of levetiracetam showed that it was safe. Topiramate has shown, among children with Tourette syndrome, effectiveness as an alternate tic treatment (Kuo et. al., 2010). It should be used as a monotherapy or adjunct therapy. In studies of children with epilepsy under the age of two, effectiveness of topiramate was shown by 73.2 percent of the medication helping reduce or eliminate seizures for children (Kim et. al., 2009).
A lot of behavioral therapies show effectiveness for both treating people with epilepsy and people with Tourette syndrome- which may help someone with both disorders. Studies on the effectiveness of physical activity on people with tic disorder showed that light exercise may alleviate tic activity whilst acute physical activity may exacerbate tics (Kim et. al., 2018). Chronic physical activity may reduce severity of tics at a higher intensity. Studies on the effectiveness of physical activity on people with epilepsy have shown that certain physical activities are beneficial to different conditions of epilepsy (Pimentel et. al., 2014). Scuba diving, skydiving, and other sports at heights may pose problems with some epilepsy, specifically uncontrolled epilepsy. Despite the physical activity, epileptic people feel an emotional benefit from physical activity in helping with depression or negative emotions of regulating their symptoms.
According to Mayo Clinic, the following are treatment options:
Medication
Medications that block or lessen dopamine: Fluphenazine, haloperidol (Haldol), risperidone (Risperdal), and pimozide (Orap), can help control tics. Possible side effects include weight gain and involuntary repetitive movements. Tetrabenazine (Xenazine) might be recommended, although it may cause severe depression.
Botulinum (Botox) injections: An injection into the affected muscle might help relieve a simple or vocal tic.
ADHD medications: Stimulants such as methylphenidate (Metadate CD, Ritalin LA, others) and medications containing dextroamphetamine (Adderall XR, Dexedrine, others) can help increase attention and concentration. However, for some people with Tourette syndrome, medications for ADHD can exacerbate tics.
Central adrenergic inhibitors: medications such as clonidine (Catapres, Kapvay) and guanfacine (Intuniv), typically prescribed for high blood pressure, might help control behavioral symptoms such as impulse control problems and rage attacks. Side effects may include sleepiness.
Antidepressants: Fluoxetine (Prozac, Sarafem, others) might help control symptoms of sadness, anxiety, and OCD.
Antiseizure medications: recent studies suggest that some people with Tourette syndrome respond to topiramate (Topamax), which is used to treat epilepsy.
Therapy
Behavior Therapy: cognitive behavioral interventions for tics, including habit-reversal training, can help you monitor tics, identify premonitory urges and learn to voluntarily move in a way that’s incompatible with the tic.
Psychotherapy: in addition to helping you cope with Tourette syndrome, psychotherapy can help with accompanying problems such as ADHD, obsessions, depression, or anxiety.
Deep Brain Stimulation (DBS): for severe tics that don’t respond to treatment, DBS might help. DBS involves implanting a battery-operated medical device in the brain to deliver electrical stimulation to targeted areas that control movement. However, this treatment is still in the early research stages and needs more research to determine if it’s a safe and effective treatment for Tourette syndrome.
(Mayo Clinic, 2018)
Conclusion
Tourette syndrome is a neurological disorder that is characterized by tics. They may be mistaken for partial epileptic seizures. Medical professionals need to address the current diagnosis used for Tourette syndrome in order to effectively help someone with either or both conditions. It is more often that Tourette syndrome occurs with epilepsy, especially in children with Tourette syndrome. Both symptoms of each disorder can be alleviated by medication or other therapies.
Resources:
Awaad, Y. (2006). the use of Levetiracetam to treat tics in children and adolescents with Tourette syndrome. Neuropediatrics, 37(S1). https://doi.org/10.1055/s-2006-945583
Hosier, G., & McKelvey, R. (2014). A case of myoclonus-dystonia diagnosed as Tourette syndrome. Dalhousie Medical Journal., 46-49. https://doi.org/10.15273/dmj.vol41no1.5940
Hung, K.L. (2017). Association of Epilepsy and Tourette Syndrome in Children. Epilepsy Journal. Retrieved from: https://doi.org/10.4172/2472-0895.1000e115
Kim, D., Warburton, D., Wu, N., Barr, A., Honer, W., & Procyshyn, R. (2018). Effects of physical activity on the symptoms of Tourette syndrome: A systematic review. European Psychiatry, 48(1), 13-19. doi:10.1016/j.eurspy.2017.11.002
Kim, J.M., Kwon, S., Seo, H.E., Choe, B.H., Cho, M.H., & Park, S.P. (2009). Long-term effectiveness of tolerability of topiramate in children with epilepsy under the age of 2 years: 4 year follow up. Journal of Korean Medical Science, 24(6), 1078. https://doi.org/10.3346/jkms.2009.24.6.1078
Krief, P., Kan, L., and Maytal, J. (2008). Efficacy of Levetiracetam in Children with Epilepsy Younger Than 2 Years of Age. Journal of Child Neurology, 23(5), 582-584. doi:10.1177/0883073807309781
Kuo, S.H., & Jimenez-Shahed, J. (2010). Topiramate in treatment of Tourette syndrome. Clinical Neuropharmacology, 33(1), 32-34. https://doi.org/10.1097/WNF.0b013e3181c295c1
Mayo Clinic (2018). Tourette Syndrome, Diagnosis and Treatment. Mayo Clinic. Retrieved from: https://www.mayoclinic.org/diseases-conditions/tourette-syndrome/diagnosis-treatment/drc-20350470
National Institute of Neurological Disorders and Stroke (2021). Tourette Syndrome Fact Sheet. National Institute of Health. Retrieved from: https://www.ninds.nih.gov/tourette-syndrome-fact-sheet
Papadopoulou, S., Pavlidou, E., Argyris, G., Flouda, T., Koukoutsidi, P., Krikonis, K., Shah, S., Chirosca-Vasileiou, D., Boussios, S. Epilepsy and Diagnostic Dilemmas: The Role of Language and Speech-Related Seizures. Journal of Personalized Medicine. 2022; 12(4): 647. https://doi.org/10.3393/jpm12040647
Pimentel, J., Tojal, R., and Morgado, J. (2014). Epilepsy and physical exercise. Seizure, (25), 87-94. Retrieved from: https://doi.org/10.1016/j.seizure.2014.09.015
Richards, H. (1995). Tics and Fits: The current status of Gilles de la Tourette Syndrome and its relationship with epilepsy. Seizure, (4) 259-266. https://doi.org/10.1016/s1059-1311(95)80002-6
Wong, L.C., Huang, H.L., Weng, W.C., Jong, Y.J., Yin, Y.J, Chen, H.A., Lee, W.T., and Ho, S.Y. (2016). Increased risk of epilepsy in children with Tourette Syndrome: A population-based case-control study. Research in Developmental Disabilities, 51-52, 181-187. https://doi.org/10.1016/j.ridd.2015.10.005
