adhd co-occurring with tics is often part of the clinical treatment of tourette's. patients who have adhd along with tourette's may also have problems with disruptive behaviors, overall functioning, and cognitive function, accounted for by the comorbid adhd, highlighting the importance of identifying and treating other conditions when present. stimulants and other medications may be useful in treating adhd when it co-occurs with tic disorders. drugs from several other classes of medications can be used when stimulants fail. there is moderate evidence supporting that clonidine combined with methylphenidate, desipramine, and methylphenidate alone reduce tics more than placebo when adhd is also present; desipramine is rarely used following reports of sudden death in children. atomoxetine does not increase tics, but may lead to weight loss and an increased heart rate. the treatment of adhd in the presence of tic disorders has long been a controversial topic. past medical practice held that stimulants (such as ritalin) could not be used in the presence of tics, due to concern that their use might worsen tics; however, multiple lines of research have shown that stimulants can be cautiously used in the presence of tic disorders. several studies have shown that stimulants do not exacerbate tics any more than placebo does, and suggest that stimulants may even reduce tic severity. controversy remains, and the pdr continues to carry a warning that stimulants should not be used in the presence of tic disorders, so physicians may be reluctant to use them. others are comfortable using them and even advocate for a stimulant trial when adhd co-occurs with tics, because the symptoms of adhd can be more impairing than tics. the stimulants are the first line of treatment for adhd, with proven efficacy, but they do fail in up to 20% of cases, even in patients without tic disorders. current prescribed stimulant medications include: methylphenidate (brand names ritalin, metadate, concerta), dextroamphetamine (dexedrine), and mixed amphetamine salts (adderall). other medications can be used when stimulants are not an option. these include the alpha-2 agonists (clonidine and guanfacine). there is good empirical support for the use of desipramine, bupropion and atomoxetine (brand name strattera). atomoxetine is the only non-controlled food and drug administration (fda) approved drug for the treatment of adhd, but is less effective than stimulants for adhd, is associated with individual cases of liver damage, carries an fda black box warning regarding suicidal ideation, and controlled studies show increases in heart rate, decreases of body weight, decreased appetite and treatment-emergent nausea. other complementary and alternative medicine approaches, such as dietary modification, neurofeedback and allergy testing and control have popular appeal, but they have no proven benefit in the management of tourette syndrome. despite this lack of evidence, up to two-thirds of parents, caregivers and individuals with ts use dietary approaches and alternative treatments and do not always inform their physicians. according to müller-vahl (2013), medical professionals "should feel obliged to inform their patients about not only effective but also ineffective treatments". there is low confidence that tics are reduced with tetrahydrocannabinol, and insufficient evidence for other cannabis-based medications in the treatment of tourette's. while a balanced diet may aid in overall health, and avoidance of caffeine may help minimize tics for some children, no particular diet or alternative therapy (vitamin or diet) is supported by scientific evidence. regular exercise can help reduce stress and improve a child's sense of accomplishment and self-esteem, but the effect of exercise on symptoms remains unstudied. there is no good evidence supporting the use of acupuncture or transcranial magnetic stimulation; neither is there evidence supporting intravenous immunoglobulin, plasma exchange, or antibiotics for the treatment of pandas. deep brain stimulation (dbs) has become a valid option for individuals with severe symptoms that do not respond to conventional therapy and management, although it is an experimental treatment. there is low-quality, limited evidence that dbs is safe, well tolerated, and yields a reduction of symptoms ranging from no change to complete remission. selecting candidates who may benefit from dbs is challenging, and the appropriate lower age range for surgery is unclear; it is potentially useful in less than 3% of individuals. the ideal brain location to target has not been identified as of 2019. dbs has been used to treat adults with severe tourette's that does not respond to conventional treatment. viswanathan a et al (2012) say that dbs should be used in patients with "severe functional impairment that can not be managed medically". pregnancy a quarter of women report that their tics increase before menstruation, however studies have not shown consistent evidence of a change in frequency or severity of tics related to pregnancy. overall, symptoms in women respond better to haloperidol than they do for men, and one report found that haloperidol was the preferred medication during pregnancy, to minimize the side effects in the mother, including low blood pressure, and anticholinergic effects. most women find they can withdraw from medication during pregnancy without much trouble. practice guidelines in 2019, the american academy of neurology (aan) published practice guidelines, "treatment of tics in people with tourette syndrome and chronic tic disorders", including 46 recommendations based on a systematic review by nine physicians, two psychologists, and two patient representatives. the panel assigned three levels of recommendations corresponding to the strength of the evidence supporting the recommendation: a: "rare because they are based on high confidence in the evidence and require both a high magnitude of benefit and low risk". b: "common because the requirements are less stringent but still based on the evidence and benefit–risk profile". c: "lowest allowable recommendation level that the aan considers useful within the scope of clinical practice and accommodates the highest degree of practice variation". the panel attached a helping verb to each level of recommendation: a = must; b = should, and c = may. description recommendation per american academy of neurology 2019 practice guidelines clinicians a: must b: should c: may counseling inform individuals and caregivers about the natural course of tic disorders y counseling evaluate tic-related impairment in functioning y counseling inform about watchful waiting for those who do not experience impairment y counseling initially prescribe comprehensive behavioral intervention for tics (cbit) for those who are motivated and without functional impairment y counseling periodically re-evaluate need for any prescribed medications for tics y psychoeducation refer teachers and peers to resources for education about ts y adhd assessment and management assess for comorbid adhd y adhd assessment and management evaluate impairment from symptoms of adhd y adhd assessment and management ensure adhd is treated when it is causing impairment y ocd assessment and management assess for comorbid ocd y ocd assessment and management ensure ocd is treated when it is present y other comorbid disorders screen for comorbid anxiety, mood, and disruptive behavior disorders y other comorbid disorders inquire about suicidal ideation and recommend resources if present y tic severity assessment measure severity of tics using a validated assessment scale y treatment expectations inform that treating tics rarely leads to complete cessation of tics y behavioral treatments for those who have access to it, prescribe cbit initially relative to other behavioral interventions y behavioral treatments offer cbit initially relative to medication y behavioral treatments if face-to-face cbit is not available, prescribe cbit via internet, or prescribe other behavioral interventions y α agonist treatment inform individuals with comorbid adhd that α2 agonists may treat both tics and adhd y α agonist treatment prescribe α2 agonists when benefits outweigh risks y α agonist treatment inform individuals treated about side effects of α2 agonists y α agonist treatment in those treated with α2 agonists, monitor heart rate and blood pressure y α agonist treatment for those taking extended release guanfacine, monitor qtc interval as indicated y α agonist treatment gradually taper α2 agonists when discontinuing them y antipsychotic treatment prescribe antipsychotics when benefit outweighs risks y antipsychotic treatment inform patients about adverse effects (extrapyramidal, hormonal, and metabolic) of antipsychotics y antipsychotic treatment prescribe lowest effective dosage of antipsychotics when using them y antipsychotic treatment when using antipsychotics, use evidence-based monitoring for drug-induced movement disorders and adverse effects y antipsychotic treatment when prescribing certain antipsychotics, monitor qtc interval and perform elecrocardiography y antipsychotic treatment gradually taper (over weeks to months) antipsychotics when discontinuing y botulinum toxin injections prescribe botulinum toxin injections for localized simple motor tics to adolescents and adults when benefits outweigh risks y botulinum toxin injections prescribe botulinum toxin injections for aggressive or disabling vocal tics to adolescents and adults when benefits outweigh risks y botulinum toxin injections inform individuals that temporary effects of botulinum toxin injections of hypophonia and weakness may occur y topiramate treatment prescribe topiramate when benefits outweigh risks y topiramate treatment inform individuals when prescribing topiramate of adverse effects y cannabis-based treatment when individuals are using cannabis as self-medication for tics, direct them to appropriate medical supervision y cannabis-based treatment for "treatment-resistant adults with clinically relevant tics", consider cannabis-based products where legislation permits it. y cannabis-based treatment for adults who already self-medicate tics with cannabis-based products, consider cannabis-based medication where legislation permits it. y cannabis-based treatment when prescribing cannabis-products where legislation permits it, use lowest effective dose y cannabis-based treatment when prescribing, inform individuals that cannabis-based products can affect driving y cannabis-based treatment when prescribing, provide ongoing re-evaluation of need y deep brain stimulation treatment employ multidisciplinary evaluation of benefits versus risks y deep brain stimulation treatment exclude secondary causes of tic-like movements and confirm ts diagnosis when considering deep brain stimulation y deep brain stimulation treatment screen for psychiatric disorders and follow deep brain stimulation subjects post-operatively y deep brain stimulation treatment before prescribing, assure that multiple classes of medications have been tried y deep brain stimulation treatment consider deep brain stimulation for "severe, self-injurious tics" y notes morand-beaulieu s, leclerc jb (january 2020). 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