Tic disorders are common, affecting approximately 0.5-1% of children and teens.  Treatment is required only when symptoms are bothersome or impairing to the patient, so many do not require interventions.  However, on occasion tics may cause significant morbidity and are referred to as “malignant.”  We describe two cases of malignant tic disorders with accompanying video, and provide aggressive management strategies for neurologists to prevent complications in these severe cases. 

Cervical myelopathy as a result of neck tics was first described in 1981.   Since then, 12 additional cases have been reported.  Along with cervical myelopathy, other complications due to self-injurious tics have included subdural hematoma secondary to head banging, biting of lips leading to infection of oral muscles, self-inflicted eye injuries leading to blindness, skeletal fractures, compressive neuropathies, and vertebral artery dissection. 

Two recent cases of malignant tics are described, including a 13 year-old male with forceful neck tics,  and a 17 year-old female with nose-rubbing tics.  The first was complicated by cervical myelopathy leading to spastic quadriplegia, while the latter resulted in significant skin breakdown, infection, and nasal deformity.  In both cases, vigorous titration of tetrabenazine led to adequate symptom control and prevented further injury.   

These two cases with video examples of malignant tics resulted in improvement of symptoms following rapid titration of tetrabenazine.  Both presented to our center after complications had occurred including cervical myelopathy and nasal breakdown. 

In general, most tic disorders can be managed conservatively with only outpatient strategies.  As malignant tics can lead to long-term disability, symptoms must be treated urgently and with all due haste in order to prevent complications.  Tetrabenazine is often the most effective and well-tolerated intervention.