Evidence-Based Reviews

Repetitive transcranial magnetic stimulation for tic disorders

Current Psychiatry. 2018 June;17(6):24-26,28,55

References

1. Landeros-Weisenberger A, Mantovani A, Motlagh MG, et al. Randomized sham controlled double-blind trial of repetitive transcranial magnetic stimulation for adults with severe Tourette syndrome. Brain Stimulat. 2015;8(3):574-581.
2. Kamble N, Netravathi M, Pal PK. Therapeutic applications of repetitive transcranial magnetic stimulation (rTMS) in movement disorders: a review. Parkinsonism Relat Disord. 2014;20(7):695-707.
3. Le K, Liu L, Sun M, et al. Transcranial magnetic stimulation at 1 Hertz improves clinical symptoms in children with Tourette syndrome for at least 6 months. J Clin Neurosci. 2013;20(2):257-262.
4. Cavanna AE, Seri S. Tourette’s syndrome. BMJ. 2013;347:f4964. doi:10.1136/bmj.f4964.
5. Leckman JF, Bloch MH, Scahill L, et al. Tourette syndrome: the self under siege. J Child Neurol. 2006;21(8):642-649.
6. Bloch MH, Peterson BS, Scahill L, et al. Adulthood outcome of tic and obsessive-compulsive symptom severity in children with Tourette syndrome. Arch Pediatr Adolesc Med. 2006;160(1):65-69.
7. Bloch M, State M, Pittenger C. Recent advances in Tourette syndrome. Curr Opin Neurol. 2011;24(2):119-125.
8. Bloch Y, Arad S, Levkovitz Y. Deep TMS add-on treatment for intractable Tourette syndrome: a feasibility study. World J Biol Psychiatry. 2016;17(7):557-561.
9. Robertson MM. The Gilles de la Tourette syndrome: the current status. Arch Dis Child Educ Pract Ed. 2012;97(5):166-175.
10. Párraga HC, Harris KM, Párraga KL, et al. An overview of the treatment of Tourette’s disorder and tics. J Child Adolesc Psychopharmacol. 2010;20(4):249-262.
11. Du JC, Chiu TF, Lee KM, et al. Tourette syndrome in children: an updated review. Pediatr Neonatol. 2010;51(5):255-264.
12. Malizia AL. What do brain imaging studies tell us about anxiety disorders? J Psychopharmacol. 1999;13(4):372-378.
13. Di Lazzaro V, Oliviero A, Berardelli A, et al. Direct demonstration of the effects of repetitive transcranial magnetic stimulation on the excitability of the human motor cortex. Exp Brain Res. 2002;144(4):549-553.
14. Olson LL, Singer HS, Goodman WK, et al. Tourette syndrome: diagnosis, strategies, therapies, pathogenesis, and future research directions. J Child Neurol. 2006;21(8):630-641.
15. Gerard E, Peterson BS. Developmental processes and brain imaging studies in Tourette syndrome. J Psychosom Res. 2003;55(1):13-22.
16. Kurlan R. Hypothesis II: Tourette’s syndrome is part of a clinical spectrum that includes normal brain development. Arch Neurol. 1994;51(11):1145-1150.
17. Peterson BS. Neuroimaging in child and adolescent neuropsychiatric disorders. J Am Acad Child Adolesc Psychiatry. 1995;34(12):1560-1576.
18. Sheppard DM, Bradshaw JL, Purcell R, et al. Tourette’s and comorbid syndromes: obsessive compulsive and attention deficit hyperactivity disorder. A common etiology? Clin Psychol Rev. 1999;19(5):531-552.
19. Bohlhalter S, Goldfine A, Matteson S, et al. Neural correlates of tic generation in Tourette syndrome: an event-related functional MRI study. Brain. 2006;129(pt 8):2029-2037.
20. Hampson M, Tokoglu F, King RA, et al. Brain areas coactivating with motor cortex during chronic motor tics and intentional movements. Biol Psychiatry. 2009;65(7):594-599.
21. Eichele H, Plessen KJ. Neural plasticity in functional and anatomical MRI studies of children with Tourette syndrome. Behav Neurol. 2013;27(1):33-45.
22. Neuner I, Schneider F, Shah NJ. Functional neuroanatomy of tics. Int Rev Neurobiol. 2013;112:35-71.
23. Mantovani A, Lisanby SH, Pieraccini F, et al. Repetitive transcranial magnetic stimulation (rTMS) in the treatment of obsessive-compulsive disorder (OCD) and Tourette’s syndrome (TS). Int J Neuropsychopharmacol. 2006;9(1):95-100.
24. Münchau A, Bloem BR, Thilo KV, et al. Repetitive transcranial magnetic stimulation for Tourette syndrome. Neurology. 2002;59(11):1789-1791.
25. Orth M, Kirby R, Richardson MP, et al. Subthreshold rTMS over pre-motor cortex has no effect on tics in patients with Gilles de la Tourette syndrome. Clin Neurophysiol. 2005;116(4):764-768.
26. Snijders AH, Bloem BR, Orth M, et al. Video assessment of rTMS for Tourette syndrome. J Neurol Neurosurg Psychiatry. 2005;76(12):1743-1744.
27. Mantovani A, Leckman JF, Grantz H, et al. Repetitive transcranial magnetic stimulation of the supplementary motor area in the treatment of Tourette syndrome: report of two cases. Clin Neurophysiol. 2007;118(10):2314-2315.
28. Chae JH, Nahas Z, Wassermann E, et al. A pilot safety study of repetitive transcranial magnetic stimulation (rTMS) in Tourette’s syndrome. Cogn Behav Neurol. 2004;17(2):109-117.
29. Wu SW, Maloney T, Gilbert DL, et al. Functional MRI-navigated repetitive transcranial magnetic stimulation over supplementary motor area in chronic tic disorders. Brain Stimul. 2014;7(2):212-218.
30. Kwon HJ, Lim WS, Lim MH, et al. 1-Hz low frequency repetitive transcranial magnetic stimulation in children with Tourette’s syndrome. Neurosci Lett. 2011;492(1):1-4.
31. Salatino A, Momo E, Nobili M, et al. Awareness of symptoms amelioration following low-frequency repetitive transcranial magnetic stimulation in a patient with Tourette syndrome and comorbid obsessive-compulsive disorder. Brain Stimulat. 2014;7(2):341-343.

Safety profile and adverse effects. In the studies we reviewed, the adverse effects associated with rTMS included headache (45%),^{1,8,24,26,28,29}scalp pain (18%),^8,30self-injurious crisis (9%),³¹ abdominal pain (9%),²⁹ red eyes (9%),²⁹ neck pain (9%),¹ muscle sprain (9%),¹ tiredness (9%),^24,26 and increase in motor excitability (9%).²⁸There were no severe adverse effects reported in any of the studies. The self-injurious crisis reported by a patient early in one study as a seizure was later ruled out after careful clinical and electroencephalographic evaluation. This patient demonstrated self-injurious behaviors prior to the treatment, and overall there was a reduction in frequency and intensity of self-injurious behavior as well as an improvement in tics.³¹

Dissimilar studies

There was great heterogeneity among the 11 studies we reviewed. One case series²⁷and one case report³¹found significant improvement in tics, but these studies did not have control groups. Both studies employed rTMS with a frequency of 1 Hz and between 900 to 1,200 pulses per day. Three open-label studies that found significant improvement in tic severity used the same frequency of stimulation (1 Hz with 1,200 pulses per day).^3,23,30All studies we analyzed differed in the total number of rTMS sessions and number of trains per stimulation.

The studies also differed in terms of the age of the participants. Some studies focused primarily on pediatric patients,^3,30 but many of them also included adults. The main limitations of the 11 studies included a small sample size,^{1,3,8,23-25,28-30} no placebo or controlled arm,^{1,3,8,23,27,30,31} concomitant psychiatric comorbidities^8,28,29or medications,^1,3,23,29,30 low stimulation intensity,^24-26 and use of short trains^24,26or unilateral cerebral stimulation.^24,26Among the blinded studies, limitations included a small sample size, prior medications used, comorbidities, low stimulation intensity, and high rTMS dose.^{1,24-26,28,29}

A possible option for treatment-resistant tics

We cannot offer a definitive conclusion on the safety and effectiveness of rTMS for the treatment of TS and other tic disorders because of the inconsistent results, heterogeneity, and small sample sizes of the studies we analyzed. Higher-quality studies failed to find evidence supporting the use of rTMS for treating TS and other tics disorders, but open-label studies and case reports found significant improvements. In light of this evidence and the treatment’s relatively favorable adverse-effects profile, rTMS might be an option for certain patients with treatment-resistant tics, particularly those with comorbid OCD symptoms.

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Repetitive transcranial magnetic stimulation for tic disorders

References

Dissimilar studies

A possible option for treatment-resistant tics

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