**4.1 Tic-suppressing drugs**

Usual medication treatment for tics centers in alpha agonists and antipsychotics. However, other types of drugs may be of benefit for patients having an inadequate response or problems with tolerability. Clonazepam has had reported modest ticsuppressing effects in published case series32.This drug may be particularly useful in patients with an associated anxiety disorder. The dopamine-depleting drug tetrabenazine has possible efficacy. The drug is marketed with restriction in some countries. In an openlabel study the drug showed sustained moderate to marked reduction in tics over an average of 2 years' follow-up33. However, only 22% of subjects were free of side effects. The most common side effects are sedation, depression, insomnia, and parkinsonism. Children may tolerate higher doses of tetrabenazine than adults34. Tetrabenazine does not cause tardive phenomena but dopamine-depleting agents can cause neuroleptic malignant syndrome even after years of use35.

Local injections of botulinum toxin can be considered when one or a few dystonic tics are present in patient's repertoire, such as holding of a sustained neck posture or sustained eye closure36, cervical tics associated with myelopathy37 and laryngeal injections for severe vocal tics, including copralalia38.
