rTMS to Reduce Tics

Tourette syndrome (TS) is characterized by multiple motor and phonic tics. Current
understanding of tic generation is thought involve the cortico-basal-thalamic-cortical
circuit. At this time, only two medications are FDA-approved for tic treatment, while many
more are used in an off-label fashion with only partial success. Despite multiple approaches
for tic suppression, patients with severe tics are often left with inadequate relief.
Repetitive Transcranial Magnetic Stimulation (RTMS) is a new technology which allows for
noninvasive stimulation of the brain. In few pilot studies, RTMS reduced tic severity when
targeting the Supplementary Motor Area (SMA). In this study, we propose to use a specific
paradigm of RTMS called Continuous Theta Burst Stimulation (cTBS) over SMA to treat
pediatric and adult patients with tics. We will utilize functional MRI (fMRI) to identify
each subject's SMA for individualized stimulation. We hypothesize that this stimulation
technique can reduce tic severity when compared to sham stimulation. This proposal is novel
because 1) cTBS is offered as a new RTMS paradigm to reduce tics and 2) combination of RTMS
and fMRI allows us to investigate the effects of cortical stimulation on the neural
correlates of tic generation.

Inclusion Criteria:1. Children or adults with Tourette Syndrome, tic disorder, chronic
motor or vocal tics disorder ages 10 to 60 years.

2. Current tics with Yale Global Tic Severity Scale (YGTSS) score > 10. 3. If subject is
on tic-suppressing medication(s) at the time of recruitment, no medication or dose changes
allowed within the past seven days.

4. If subject receives botulinum toxin injection for tic management, the injection must be
at least twelve weeks prior to the day of the study.

5. After the TBS sessions, no tic-suppression medications can be changed for at least one
week.

6. All patients ages 10 to 60 years old with Tourette Syndrome, tic disorder, chronic
motor or vocal tics disorder will be offered to participate in the study. If the patient
decides to participate in the study, our study coordinator will obtain informed consent
from the adult participant, or at least one parent of the pediatric participant. The
consent form is written in English; the form is also written in a manner understandable by
the person signing the form. The adult participant, the parent(s) of participant or the
pediatric participant does not have to make a decision at the time of clinic visit, thus,
minimizing coercion to participate.

-

Exclusion Criteria:1. Implanted brain stimulator, vagal nerve stimulator, VP shunt,
aneurysm clip, cardiac pacemaker, or implanted medication port.

2. Prior ischemic or hemorrhagic stroke or traumatic brain injury. 3. History of seizure
or epilepsy 4. If female, pregnant or sexually active and not using birth control.
Abstinence will be permitted at the discretion of the TS clinicians, consistent with other
IRB approved studies involving this population.

-