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Premonitory urge

A premonitory urge is an uncomfortable sensory phenomenon that precedes tics in individuals with tic disorders, such as Tourette syndrome, characterized by a mounting inner tension, itch, or pressure that builds in intensity and is typically relieved by performing the associated tic.^[1] These urges are often localized to specific body regions, such as the eyes, throat, or limbs, and can manifest as restlessness or a "just right" feeling that demands resolution through motor action.^[2] First detailed in clinical literature by patient and researcher James Bliss in 1980, who described them as preliminary sensations akin to an intolerable buildup preceding tic execution, premonitory urges have since been recognized as a core feature distinguishing tic disorders from other hyperkinetic movements.^[1] Premonitory urges are reported by a substantial majority of individuals with Tourette syndrome, with prevalence estimates ranging from 70% to over 90%.^[1] They typically emerge several years after initial tic onset, more reliably in adolescents and adults than in young children. Their intensity can fluctuate, influenced by factors like stress or comorbidities such as obsessive-compulsive disorder (OCD), where urges may take on a more cognitive "not just right" quality.^[2] From a neurobiological perspective, premonitory urges are linked to dysfunction in brain regions involved in interoception and motor preparation.^[1] Ongoing research as of 2025, including Phase III trials of ecopipam and studies on neuromodulation, continues to explore mechanisms and targeted interventions to modulate urge generation.^[2]^[3]^[4]

Definition and Characteristics

Definition

A premonitory urge refers to an uncomfortable sensory or emotional phenomenon that precedes the execution of motor or vocal tics in individuals with tic disorders, often characterized as a mounting inner tension or compulsion to perform a specific movement or sound.^[1] These urges are subjective experiences that signal an impending tic and are typically relieved upon tic expression, functioning through a mechanism of negative reinforcement where the discomfort dissipates temporarily after the tic occurs.^[5] Unlike the observable tics themselves, which are the involuntary motor or vocal behaviors, premonitory urges represent the internal, aversive buildup of sensation—such as pressure or itch-like tension—that intensifies until the tic is enacted as a voluntary response to alleviate it.^[6] This distinction underscores urges as a hallmark sensory feature in tic disorders, distinguishing them from purely automatic movements by involving conscious awareness and potential suppression, though resistance often heightens the discomfort.^[7] The concept of premonitory urges was first systematically documented in a 1993 study by Leckman, Walker, and Cohen, which examined 135 individuals with tic disorders and found that 93% reported experiencing such urges preceding their tics, with 84% noting relief following tic performance.^[1] This work established urges as a central aspect of tic phenomenology, particularly in Tourette syndrome, where they contribute to the subjective burden of the disorder.

Sensory Features

Premonitory urges are commonly described as uncomfortable sensory experiences localized to the body part involved in the impending tic, including sensations of itch, tingle, pressure, or warmth.^[1] Patients often report a subjective "not just right" feeling, characterized by a sense of incompleteness or discomfort that demands resolution through tic execution.^[8] These sensations are typically aversive and physical in nature, distinguishing them from purely cognitive impulses.^[9] The intensity of premonitory urges often begins mildly but escalates progressively if the tic is suppressed, resulting in mounting inner tension or discomfort that peaks just before the tic occurs.^[1] This buildup can become highly distressing, with relief achieved transiently upon performing the tic, thereby reinforcing the urge-tic cycle.^[10] In clinical descriptions, the urge's strength is rated variably, often on scales from mild annoyance to intense pressure, and its association with overall tic severity varies, with some studies reporting positive correlations.^[11] Premonitory urges exhibit considerable variability in their manifestation, ranging from focal sensations confined to specific muscle groups (e.g., tension in the shoulders or neck) to more generalized whole-body discomfort.^[9] They may also be accompanied by emotional components, such as anxiety or frustration, particularly when suppression prolongs the experience.^[8] Individual differences are pronounced, with some patients experiencing urges before most tics while others report them inconsistently.^[10] These urges typically endure for seconds to minutes prior to tic expression, providing a brief window of escalating discomfort that resolves shortly after the tic is performed.^[11] Their transient nature underscores their role as immediate precursors to tics, though duration can vary based on suppression efforts.^[1]

Epidemiology

Prevalence

Premonitory urges are reported in 37% to 93% of individuals with primary tic disorders.^[12] Rates are generally higher in Tourette syndrome (TS), where prevalence estimates range from 70% to 93%, reflecting the more chronic and complex nature of tics in this condition.^[13]^[2] In a seminal study of 28 individuals with TS, nearly 80% endorsed experiencing premonitory urges preceding their tics.^[14] Given the global prevalence of TS at approximately 0.77% among children (with broader estimates for tic disorders up to 2.99%), premonitory urges affect a substantial subset of those impacted by these conditions.^[15] Reporting of premonitory urges tends to be higher among adolescents and adults, likely due to improved self-awareness and verbalization skills compared to younger children. In a large-scale study of 656 children and adolescents with chronic tic disorders aged 3 to 16 years, prevalence was 81% among those aged 7 years and younger, rising to 97.5% in those over 10 years.^[16] This age-related increase aligns with patterns observed in developmental trajectories.^[2]

Developmental Patterns

Premonitory urges in individuals with tic disorders typically emerge several years after the initial onset of tics, with awareness developing at an average age of 10 years, approximately 3.1 years (SD = 5.7) following tic onset.^[11] This delay aligns with the general age of tic onset around 5–7 years, placing the appearance of urges in late childhood or early adolescence, often between ages 8 and 12.^[17] Seminal studies indicate that urges are rarely reported in very young children under 8 years, with prevalence rates as low as 81% in this group compared to 95.5% in ages 8–10 and 97.5% in those over 10.^[11] In childhood, premonitory urges are less frequently recognized or intense due to developmental limitations in sensory awareness and verbalization, whereas they become more prominent and distressing following puberty.^[17] Scores on the Premonitory Urge for Tics Scale (PUTS) are notably higher in older children (ages 12–15) than in younger ones (ages 6–11), reflecting increased subjective experience.^[11] In adulthood, urges persist in chronic cases such as Tourette syndrome (TS), with endorsement rates reaching 93% across ages 8–71, often maintaining or slightly exceeding adolescent levels in severity.^[11] The evolution of premonitory urges often parallels tic severity, intensifying as tics worsen, particularly during periods of heightened stress or hormonal changes in adolescence.^[17] With growing awareness, individuals may develop improved skills for voluntary tic suppression, as urges are frequently described as irresistible tensions relieved only by tic execution, enabling conscious delay in some cases. Longitudinal data, though limited, demonstrate stability or gradual increase in urge intensity in TS; for instance, PUTS scores rose from a mean of 13.5 at age 7.3 to 24.1 at age 13.1 over several years.^[11] In contrast, urges in transient tic disorders tend to wane as tics remit, with rare reporting in provisional cases compared to chronic forms.^[18]

Clinical Assessment

Diagnostic Criteria

Premonitory urges are not a required diagnostic criterion for Tourette syndrome or other tic disorders in the DSM-5 or ICD-11, but their presence serves as supportive evidence, helping to confirm chronicity and differentiate tics from other stereotypic movements or functional behaviors.^[19]^[20]^[21] In clinical evaluation, premonitory urges are identified primarily through detailed patient history, where individuals describe uncomfortable sensory experiences preceding tics, often building in intensity until the tic provides relief.^[19] The report of such urges strongly suggests a primary tic disorder rather than secondary causes, such as those induced by medications, substances, or neurological conditions like Huntington's disease, as they are rarely endorsed in those contexts.^[22]^[23] These urges are distinguished from voluntary habits or mannerisms by their involuntary, tic-specific nature and the characteristic post-tic relief, which reduces the sensory discomfort and is not typically experienced in purposeful behaviors.^[22]^[24] Unlike compulsive behaviors in other conditions, premonitory urges lack an obsessional trigger and are often localized to the body part involved in the impending tic.^[9] Challenges in diagnosis include the underreporting of premonitory urges among children, where they may emerge several years after tic onset and are less reliably articulated due to developmental factors.^[25] Additionally, clinicians must differentiate tic-related urges from sensory phenomena in obsessive-compulsive disorder, such as "just right" feelings or incompleteness, which are more closely tied to anxiety reduction through rituals rather than localized sensory buildup relieved specifically by the tic.^[26]^[9]

Measurement Tools

The Premonitory Urge for Tics Scale (PUTS) is a widely used self-report instrument designed to quantify the frequency, intensity, and associated distress of premonitory urges in individuals with tic disorders. Developed by Woods et al. in 2005, the original version consists of 10 items, with the first item serving as a screening question and the remaining nine contributing to the total score, which ranges from 9 to 36.^[27] In clinical and research settings, the PUTS is administered to patients aged 8 years and older, typically taking 5-10 minutes to complete, and helps track changes in urge severity over time or in response to interventions.^[27] A revised version, the Premonitory Urges for Tic Disorders Scale–Revised (PUTS-R), developed in 2020, rephrases existing items, removes the suppressibility item, adds new items to assess urge quality and severity (proposing up to 24 items), and uses a 5-point Likert scale (0-4) for enhanced sensitivity and reliability across age groups.^[28] The Individualized Premonitory Urge for Tics Scale (I-PUTS), introduced by McGuire et al. in 2016, complements the PUTS as a clinician-administered tool tailored to individual experiences. This scale involves a semi-structured interview where clinicians guide patients to identify and rate personalized premonitory sensations using a visual analog scale for intensity and a checklist of common urge descriptors, enabling precise mapping of urge-tic relationships in both research protocols and personalized treatment planning.^[29] It is particularly valuable in clinical assessments for capturing nuances that standardized self-reports may overlook, such as spatial localization of urges corresponding to specific tics.^[30] The University of São Paulo Sensory Phenomena Scale (USP-SPS), developed in 2011, is a clinician-rated instrument that assesses various sensory phenomena, including premonitory urges, preceding or accompanying tics. It includes a checklist of seven types of sensory phenomena (e.g., localized discomfort, urge-only sensations) and a severity subscale rating their intensity and impact on a 0-5 scale. A Short Form (USP-SPS-SF) condenses this for quicker administration while retaining key items for urge evaluation. The USP-SPS is used in both clinical diagnostics and research to differentiate tic-related urges from other sensory experiences, with good psychometric properties validated in multiple languages.^[1]^[31] Additional methods for measuring premonitory urges include real-time tracking via live urge monitors and integration with broader tic severity assessments. Live urge monitors, employed in experimental studies, allow participants to continuously rate urge intensity on a digital slider during observation sessions, facilitating analysis of temporal dynamics between urges and tic expression without retrospective bias.^[2] For instance, such monitors have revealed that urge buildup often precedes tics by seconds to minutes, with intensity peaking just before tic release.^[32] The Yale Global Tic Severity Scale (YGTSS), a clinician-rated measure of overall tic impairment, is frequently paired with urge-specific tools like the PUTS to correlate premonitory sensations with tic frequency, complexity, and interference, providing a multidimensional view of symptom interplay in research and diagnostics.^[33] Validation efforts have established the PUTS and its variants as reliable across diverse populations, with translations enhancing global applicability. The scale has been adapted into languages such as Chinese and Spanish, demonstrating strong internal consistency (Cronbach's α > 0.80) and test-retest reliability in these versions, suitable for children and adolescents starting from age 8.^[34]^[35] However, limitations include inherent subjectivity in self-reported sensations, which can vary by individual awareness, and potential underreporting among younger children due to limited verbal articulation or developmental differences in urge recognition.^[36] These tools remain essential for both empirical studies on urge phenomenology and clinical monitoring in tic disorders.

Neurobiology

Brain Regions

Premonitory urges in tic disorders, particularly Tourette syndrome, have been linked to several key brain regions through neuroimaging studies. The insula plays a central role in sensory integration underlying these urges, with functional magnetic resonance imaging (fMRI) studies showing activation in the anterior and posterior insula prior to tic onset.^[37] The supplementary motor area (SMA) is implicated in urge initiation, exhibiting increased activity in the seconds leading up to tics. Similarly, the sensorimotor cortex contributes to the localization of urges, with fMRI evidence of activation during the pre-tic phase. Structural neuroimaging, including voxel-based morphometry (VBM) and cortical thickness analyses, reveals reduced grey matter volume in the insula and sensorimotor cortex among individuals with more severe premonitory urges. The putamen, a component of the basal ganglia, shows involvement in the linkage between urges and tic expression, with fMRI demonstrating activation approximately one second before tic execution. Altered functional connectivity patterns further highlight these regions' roles. Specifically, increased connectivity between the right dorsal anterior insula and the basal ganglia, including the putamen, has been observed in relation to urge intensity.^[38] Additionally, variations in gamma-aminobutyric acid (GABA) concentrations in the SMA correlate with the frequency and intensity of premonitory urges, with lower GABA+ levels associated with heightened urge severity. These findings from fMRI and magnetic resonance spectroscopy underscore the distributed neural correlates without implying directional causality. Recent neuroimaging research as of 2024 has further emphasized the insula's critical role in action-related functional networks for tic generation and premonitory urges.^[39]

Mechanisms

The premonitory urge in tic disorders is hypothesized to arise through a negative reinforcement model, wherein the urge builds as an aversive sensation that is temporarily relieved by the execution of a tic, thereby perpetuating the tic behavior. This process was first articulated in detail by Bliss in 1980, who described the intentionality of tics as driven by mounting sensory discomfort that compels action for relief. Experimental evidence shows that tic suppression can lead to a rebound effect in tic frequency upon release, consistent with negative reinforcement dynamics in cortico-striato-thalamo-cortical (CSTC) circuits, though effects on urge intensity vary across studies.^[40] Central to this model is dopaminergic dysregulation within the CSTC loops, where imbalances in striatal dopamine signaling contribute to the buildup of urge intensity and the subsequent drive for tic expression.^[41] Hyperdopaminergic activity in the ventral striatum, for instance, has been linked to heightened sensory processing and motor inhibition failure, amplifying the discomfort that precedes tics. These circuit-level disruptions integrate sensory input with motor output, fostering a cycle where the urge serves as a signal for tic release to restore homeostasis. Sensory-motor integration further underlies urge generation, particularly through loops involving the insula and supplementary motor area (SMA), which process interoceptive discomfort and prepare motor responses.^[41] The insula detects localized tension or "itch-like" sensations, while the SMA coordinates the mounting pressure toward action, creating a feedback loop that heightens urge perception until tic performance alleviates it. Tic suppression in this pathway may exacerbate the urge via a rebound phenomenon, mirroring patterns observed in behavioral studies of urge-tic associations. Comorbidities with obsessive-compulsive disorder (OCD) highlight shared mechanisms, such as "not just right" experiences—feelings of incompleteness that parallel premonitory urges—mediated by orbitofrontal cortex involvement in CSTC circuits. In individuals with both Tourette syndrome and OCD, these sensations often drive repetitive behaviors beyond simple tics, with up to 90% reporting such perceptual overlaps.^[41] This convergence suggests orbitofrontal hyperactivity contributes to a common pathway of discomfort-driven compulsion. Despite these insights, significant gaps persist in understanding whether premonitory urges causally precede or result from tics, as well as the precise directionality in their reinforcement.^[41] Limited real-time neuroimaging data hinders elucidation of dynamic urge-tic interactions, with calls for advanced techniques to capture transient processes in vivo. A 2025 scoping review confirms ongoing uncertainties in the mechanistic relationship between premonitory urges and tics.^[2]

Association with Disorders

In Tourette Syndrome

In Tourette syndrome (TS), premonitory urges manifest as uncomfortable sensory sensations that precede tics, often described as localized tension, pressure, or itchiness that builds until relieved by tic execution. These urges are a core feature of TS, distinguishing it from other conditions, and are reported by 70-90% of patients.^[11] The prevalence correlates positively with tic severity, where higher urge intensity accounts for up to 30% of the variance in tic expression, and with disease chronicity, as urges typically emerge several years after initial tic onset, becoming more prevalent in adolescents and adults.^[42]^[2] Premonitory urges contribute significantly to psychological distress and impaired quality of life in TS, often exacerbating functional limitations beyond the tics themselves. In a seminal study, nearly 60% of participants indicated that the urges were more bothersome than the tics they preceded.^[2] This distress arises from the mounting discomfort that pressures tic performance, leading to cycles of tension and temporary relief, which can interfere with daily activities and social interactions. Urges show specificity to tic characteristics in TS, with stronger associations observed in complex tics compared to simple ones—for instance, 80% of complex motor tics are preceded by urges versus 67% of simple motor tics.^[2] Their post-onset development facilitates tic suppression strategies, as patients learn to recognize and endure the sensations, though this awareness intensifies the subjective burden. Comorbid obsessive-compulsive disorder (OCD) heightens the experience of premonitory urges in TS, with strong correlations between urge severity and OCD symptom intensity, and sensory phenomena overlapping significantly between the conditions.^[43] This comorbidity amplifies the overall clinical burden, particularly through a more pronounced "not-just-right" quality in urges, as up to 93% of TS patients overall report urges.^[2]^[13]

In Other Tic Disorders

Premonitory urges occur in persistent (chronic) motor or vocal tic disorder, though at rates of approximately 50% to 70%, which are generally lower than in Tourette syndrome.^[11] These urges are often less intense and associated with simpler, less complex tics compared to the multifaceted presentations in Tourette syndrome, potentially reflecting the disorder's focus on either motor or vocal tics without the combined symptomatology.^[44] The sensations may provide transient relief upon tic execution, similar to the core mechanism in other tic disorders, but their reduced prominence contributes to milder overall distress.^[11] In provisional tic disorder, premonitory urges are reported at lower rates, ranging from 37% to 50%, consistent with the transient and typically milder nature of tics in this condition, which often affects younger children.^[11] These urges may not fully develop or persist due to the short duration of symptoms, usually resolving within a year, and are less likely to correlate strongly with tic severity than in chronic forms.^[44] This limited expression underscores the developmental aspect of urge emergence, which tends to increase with age across tic disorders.

Treatment Approaches

Behavioral Therapies

Behavioral therapies for premonitory urges in tic disorders primarily involve non-pharmacological strategies that enhance awareness of sensory phenomena preceding tics and promote alternative responses to manage them. The Comprehensive Behavioral Intervention for Tics (CBIT) is a widely adopted, evidence-based approach that incorporates habit reversal training (HRT) as its core component. HRT teaches individuals to recognize premonitory urges—such as itching or pressure sensations—and replace tic behaviors with competing responses, like deep breathing for vocal tics or muscle relaxation for motor tics, thereby improving overall tic control despite limited direct reduction in urge intensity.^[45]^[46] Awareness training, a key element within HRT and CBIT, focuses on identifying and labeling premonitory urges to facilitate better suppression. This training often utilizes tools like the Premonitory Urge for Tics Scale (PUTS) to quantify urge frequency and severity, enabling patients, particularly adolescents, to develop metacognitive skills for urge monitoring. Studies indicate that heightened premonitory awareness correlates with improved tic suppression ability in youth.^[47]^[45] Exposure and Response Prevention (ERP) represents another targeted behavioral strategy, emphasizing prolonged exposure to premonitory urges while actively suppressing tics to disrupt the urge-tic-relief cycle. Patients practice enduring the discomfort of urges without performing the tic, which over time may reduce urge intensity through mechanisms like inhibitory learning rather than habituation. ERP is particularly useful for those with strong sensory triggers and can be delivered in individual or internet-based formats.^[48] Clinical evidence for these therapies shows mixed results, with tic severity reductions of 30% to 50% on scales like the Yale Global Tic Severity Scale (YGTSS) following CBIT or ERP, comparable to pharmacological options in randomized trials. However, premonitory urges often persist in approximately 40% to 60% of cases post-treatment, with higher baseline urge severity predicting poorer tic improvement and no substantial within-session habituation observed during ERP. These interventions remain first-line for mild to moderate cases, demonstrating sustained benefits up to 12 months in responders. A 2025 scoping review notes limited evidence on urge-specific responses but highlights promising behavioral approaches.^[46]^[48]^[45]^[2]

Pharmacological and Neuromodulation Options

Pharmacological interventions for premonitory urges primarily target underlying neurotransmitter imbalances in tic disorders such as Tourette syndrome (TS). Topiramate, an antiepileptic agent that enhances GABAergic transmission and inhibits glutamatergic activity, has demonstrated efficacy in reducing both tic severity and premonitory urge intensity.^[9] In a randomized, double-blind, placebo-controlled trial involving 29 patients with TS aged 7–65 years, topiramate (mean dose 118 mg/day, titrated up to 200 mg/day) led to significant improvements in Yale Global Tic Severity Scale (YGTSS) total tic scores compared to placebo (mean reduction of 14.29 vs. 5.0 points over 10 weeks), with patients reporting subjective alleviation of premonitory urges, though not formally quantified.^[49] A subsequent meta-analysis of 14 trials confirmed topiramate's role in tic reduction (mean YGTSS decrease of 7.74 points), supporting its use for mild to moderate cases where urges contribute to tic expression.^[50] Aripiprazole, a partial dopamine D2 receptor agonist and serotonin modulator that stabilizes dopaminergic activity, is commonly employed for tic management and has been evaluated for its impact on premonitory urges. In an open-label study of 18 adults with TS, aripiprazole (mean dose 12.2 mg/day for 4–6 weeks) significantly reduced tic severity (YGTSS total tic score decrease of 3.5 points, p=0.027), but showed no statistically significant change in premonitory urge scores on the Premonitory Urge for Tics Scale (PUTS; p=0.917).^[51] Despite this, its dopamine-stabilizing properties may indirectly mitigate urge-related distress in some patients, as evidenced by overall improvements in quality of life and comorbidities. Common side effects include sleep disturbances (44.4% of patients) and restlessness (16.7%), with weight gain reported in broader antipsychotic use.^[51] Botulinum toxin injections offer a targeted approach for focal tics accompanied by premonitory urges, particularly cranial or vocal manifestations. By inhibiting acetylcholine release at the neuromuscular junction, it weakens specific muscles, thereby reducing tic frequency and associated sensory discomfort. A randomized, placebo-controlled trial demonstrated a median net tic reduction of 37% (p=0.0007) and a significant decrease in urge intensity (net change of -0.94 on a visual analog scale, 95% CI -1.71 to -0.81, p<0.02).^[52] Case series and a scoping review indicate effectiveness in up to 84% of patients for persistent urges with motor tics, with benefits lasting 3–4 months per injection cycle.^[2] Side effects are generally mild, including transient injection-site pain and muscle weakness, though persistent urges may lead to discontinuation in a minority of cases.^[52] Neuromodulation techniques provide non-pharmacological options for refractory premonitory urges by directly altering neural circuit activity. Deep brain stimulation (DBS) targets key nodes in the cortico-striato-thalamo-cortical pathway, such as the globus pallidus internus (GPi) or thalamic nuclei (e.g., centromedian-parafascicular/ventral oral complex), to suppress aberrant signals linked to urges. In case reports of two adult males with severe, refractory TS, bilateral thalamic DBS over two years yielded consistent reductions in premonitory urges (PUTS scores improved alongside YGTSS tic scores) and enhanced global functioning.^[53] A randomized sham-controlled trial comparing GPi and thalamic DBS reported superior initial tic reductions with GPi stimulation (up to 50% in some cohorts), though long-term benefits waned in half of patients; DBS remains reserved for adults with treatment-resistant cases due to surgical risks.^[54] Repetitive transcranial magnetic stimulation (rTMS), a non-invasive method, applies low-frequency pulses to the supplementary motor area (SMA) to inhibit hyperactivity associated with urge generation. A meta-analysis of rTMS studies in TS found a moderate effect on premonitory urge severity (Hedges' g=0.63, 95% CI 0.09–1.17, p<0.02), with small trials reporting 20–40% reductions in urge and tic scores following bilateral SMA protocols (1 Hz, 110% resting motor threshold over 10–40 sessions).^[55] For instance, low-frequency rTMS to the SMA or adjacent parietal regions alleviated urges in pediatric and adult cohorts, with effects persisting 1–3 months post-treatment.^[56] This approach shows promise for milder refractory cases but requires larger trials to optimize parameters and confirm durability.^[55]

History and Research

Early Observations

In his seminal 1885 description of what would later be known as Tourette syndrome, Georges Gilles de la Tourette documented cases involving multiple motor and vocal tics, although he did not explicitly conceptualize these as premonitory urges.^[1] This early observation highlighted subjective discomfort building prior to tic expression, but the emphasis remained on the observable behaviors rather than the internal experiences. Throughout the late 19th and early 20th centuries, scattered reports in French neurological literature described similar sensory phenomena preceding tics, often termed "incomplete" or unfulfilled sensations that demanded resolution through movement. For instance, in their influential 1902 monograph Les Tics et Leur Traitement, Henri Meige and William Feindel detailed numerous patient cases involving disagreeable pre-tic sensations, such as dragging, stiffness, or tingling in affected muscles and joints, which prompted voluntary actions that evolved into habitual tics.^[57] These accounts portrayed the sensations as variable and subjective, sometimes akin to fatigue or constriction, but frequently overlooked in favor of classifying and treating the motor manifestations. Such pre-tic experiences were largely sidelined in early clinical discourse, as diagnostic and therapeutic attention centered on the visible tics themselves, with internal urges viewed as secondary or incidental to the disorder's pathology. This oversight persisted until more systematic patient self-reports emerged. A pivotal shift occurred in 1980 with the publication of Joseph Bliss's autobiography-like account, the first detailed documentation of premonitory urges by an individual with a 62-year history of Tourette syndrome. Bliss described "preliminary sensations" or "discrete sensations" that built rapidly as an insistent, escalating desire for movement to relieve discomfort, characterizing tics as intentional responses to these urges rather than purely involuntary acts. His observations, drawn from decades of self-monitoring, underscored the voluntary yet compulsive nature of tic execution in response to sensory imperatives.

Key Studies and Advances

In the early 1990s, systematic studies began to quantify the prevalence and impact of premonitory urges in Tourette syndrome (TS). Cohen and Leckman (1992) surveyed 28 individuals with TS, finding that 82% experienced premonitory urges prior to motor and vocal tics, often described as uncomfortable sensory phenomena that caused significant distress.^[14] Building on this, Leckman et al. (1993) expanded the sample to 135 participants aged 8–71 years with tic disorders, reporting a 93% prevalence of premonitory urges, which were associated with heightened anxiety and interference in daily functioning, thereby establishing urges as a core, distressing feature rather than a mere byproduct of tics.^[13] A major methodological advance occurred in 2005 with the development of the Premonitory Urge for Tics Scale (PUTS) by Woods et al., a 10-item self-report instrument designed for youths with TS or chronic tic disorders.^[27] Initial psychometric evaluation in 42 participants demonstrated strong internal consistency (Cronbach's α = 0.82) and test-retest reliability, enabling standardized, quantitative assessment of urge intensity, frequency, and interference, which facilitated subsequent empirical research on urge phenomenology.^[27] During the 2010s, neuroimaging studies provided neurobiological insights into premonitory urges. Draper et al. (2016) used structural MRI in 29 young people with TS and 29 controls, revealing that higher PUTS scores correlated with reduced grey matter thickness in the right insula and sensorimotor cortex, suggesting these regions underpin urge generation and intensity.^[58] Complementing this, Rae et al. (2019) proposed a Bayesian computational model of sensory-motor interactions in TS, integrating fMRI data from 18 TS patients and 19 controls to show that over-precise priors in somatomotor networks amplify premonitory sensations, driving tic expression as a form of sensory attenuation.^[59] In the 2020s, scoping reviews and emerging interventions have highlighted research gaps and therapeutic potential. Wohlgemuth et al. (2025) conducted a comprehensive review of 102 studies on premonitory urges in tic disorders, identifying high prevalence (up to 95% in adults) but noting critical deficiencies in longitudinal data, standardized measurement across ages, and mechanistic studies beyond TS.^[2] Concurrently, repetitive transcranial magnetic stimulation (rTMS) trials have shown promise; for instance, Fu et al. (2021) applied low-frequency rTMS to the bilateral parietal cortex in 30 TS patients (randomized to active or sham), resulting in significant reductions in premonitory urge severity (PUTS scores, p < 0.001) alongside tic improvement, without major adverse effects.^[60] These milestones reflect a broader paradigm shift in TS research, from viewing tics as isolated motor events to incorporating premonitory urges as central drivers, informing urge-inclusive diagnostic criteria and enhancing behavioral and neuromodulatory therapies.^[2]

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The large variation in methodology has led to a reported prevalence between 3:1000 and 8:1000 children. Males are more commonly affected than females with a ...
[22]
Diagnosing Tic Disorders | Tourette Syndrome - CDC
Jul 24, 2025 · Three tic disorders are included in the DSM-5-TR:1. Tourette syndrome (TS, sometimes called Tourette disorder). People with Tourette syndrome ...
[23]
European clinical guidelines for Tourette syndrome and other tic ...
Nov 25, 2021 · Stimulant use as a specific cause of tics has been removed. In ICD-11, TS is removed from the category of emotional disorders and classified ...
[24]
Neurobiology of the Premonitory Urge in Tourette's Syndrome
Jan 25, 2017 · The presence of such sensory symptoms or “premonitory urges” to tic is useful in the differential diagnosis between tics and other repetitive ...
[25]
Distinguishing functional from primary tics: a study of expert video ...
The top clinical information factors most relevant for the diagnosis of primary tics were knowledge on the presence of premonitory urges and tic suppressibility ...Methods · Results · Discussion
[26]
Non-just-right experiences are more closely related to OCD than tics ...
Nov 10, 2023 · The majority of adult patients with Tourette syndrome report experiencing premonitory urges before tics. Some of these experiences have been ...
[27]
Premonitory Urge for Tics Scale (PUTS): initial psychometric results ...
The current study of 42 youths with TS or CTD presents initial psychometric data for a new, brief self-report scale designed to measure tic-related premonitory ...Missing: paper | Show results with:paper
[28]
Developing the Premonitory Urges for Tic Disorders Scale–Revised ...
Jun 16, 2020 · This scale was developed by Woods, Piacentini, Himle, and Chang (2005) and is a short, easily administered questionnaire. PUTS has been shown to ...
[29]
An Individualized Premonitory Urge for Tics Scale - PubMed
This study examined the psychometric properties of a novel scale called the Individualized Premonitory Urge for Tics Scale (I-PUTS) that assesses urge ...
[30]
An Individualized Premonitory Urge for Tics Scale - PMC
Sep 9, 2016 · Premonitory urges are unpleasant aversive sensations that precede tics, and are temporarily reduced or relived by the performance of tics ( ...
[31]
Temporal relationship between premonitory urges and tics in Gilles ...
A few studies have utilized a live urge monitor to examine the relationship between urges and tics in real time. Brandt et al. assessed real-time urge intensity ...
[32]
Tic disorders and the premonitory urge
Dec 23, 2009 · Woods et al. (2005) found PUTS severity to be correlated with tic severity as measured by the Yale Global Tic Severity Scale (YGTSS, Leckman et ...
[33]
Clinical evaluation of premonitory urges in children and adolescents ...
Nov 16, 2023 · The C-IPUTS can be used to assess PUs reliably and effectively and provide further information for the C-PUTS from various dimensions in a Chinese setting.
[34]
Tic disorders and premonitory urges: validation of the Spanish ...
Conclusions: The Spanish-language version of the PUTS is a valid, reliable tool for assessing premonitory urges in both children and adolescents, especially ...Missing: translations Chinese
[35]
The Premonitory Urge for Tics Scale in a large sample of children ...
Dec 4, 2019 · The Premonitory Urge for Tics Scale (PUTS) is the most frequently used self-report measure to assess the severity of premonitory urges.Missing: subjectivity underreporting
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https://pmc.ncbi.nlm.nih.gov/articles/PMC7501098/
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https://doi.org/10.1093/brain/awl050
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https://doi.org/10.1002/mds.26230
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https://www.nature.com/articles/s41467-024-55242-6
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https://doi.org/10.1016/j.brat.2012.09.009
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Premonitory Urges and Their Link With Tic Severity in Children ... - NIH
Aug 14, 2019 · In the current study we could demonstrate that premonitory urges can predict almost 30% of the variance of tic severity, and this finding ...
[42]
Sensory phenomena related to tics, obsessive-compulsive ...
Sensory phenomena, including premonitory urges, are experienced by patients with Tourette syndrome (TS) and obsessive-compulsive disorder (OCD).Missing: differentiate | Show results with:differentiate<|control11|><|separator|>
[43]
Premonitory Urges and Their Link With Tic Severity in Children and ...
Aug 13, 2019 · Differences in the reported prevalence of chronic tic disorders from 0.5% to 4% (3–7) may be due to the fact that most cases of tics are mild ...<|control11|><|separator|>
[44]
Poststreptococcal Movement Disorders | Neurobiology of Disease
Sensory phenomena, similar to tic-related premonitory urges, were reported in one study,36 but this needs replication. SC patients exhibit motor ...
[45]
Review of habit reversal training for tic disorders - PMC - NIH
However, it does not substantially improve premonitory urges. The emergence of CBIT indicates that HRT needs further development and updating. Continuous ...
[46]
Moderators and predictors of response to behavior therapy for tics in ...
Mar 14, 2017 · This study provides Class I evidence that CBIT is effective in reducing tic severity across subgroups of patients with chronic tic disorders ...
[47]
Premonitory Awareness Facilitates Tic Suppression - PubMed Central
Jul 3, 2020 · Only 37% of patients with TS reported premonitory urges; however, 64% reported that they could suppress tics (9). Moreover, Woods et al ...
[48]
No Evidence for within-Session Habituation to Premonitory Urges
Nov 14, 2023 · Most evidence is currently available for HRT, which has been investigated in children and adults from 1973 onwards [15,17,18,19,20,21,22].
[49]
A randomised, double-blind, placebo-controlled study of topiramate ...
This double-blind, placebo-controlled trial provides evidence that topiramate may have utility in the treatment of moderately severe TS.Missing: pharmacological | Show results with:pharmacological<|control11|><|separator|>
[50]
Current Management of Tics and Tourette Syndrome: Behavioral ...
Additionally, patients in the topiramate group showed improvement in premonitory urge, but this effect was not quantified. A meta-analysis evaluating 14 trials ...Review · Nonpharmacological... · New And Emerging Therapies
[51]
Aripiprazole Improves Associated Comorbid Conditions in Addition ...
Our results suggest that aripiprazole may improve associated comorbid conditions in addition to tics in patients with GTS.
[52]
Toxin for Tics: Practical Guidance for Clinicians from a Registry ... - NIH
Botulinum toxin resulted in a net decrease in urge of 0.94 (95% CI −1.71, −0.81, P < 0.02), relative to placebo. We believe that the mechanism of botulinum ...
[53]
Sensory Phenomena and Obsessive-Compulsive Symptoms in ...
We report on two male patients who showed consistent improvement in tics, premonitory urges, and global functioning two years after DBS. In contrast, there were ...
[54]
Randomized double-blind sham-controlled trial of thalamic versus ...
Background: There are still no sufficient data regarding the use of deep brain stimulation (DBS) in Gilles de la Tourette syndrome (GTS) and no agreement on ...
[55]
A meta-analysis of transcranial magnetic stimulation in Tourette ...
This meta-analysis examined the efficacy of TMS to reduce tic severity in patients with TS. Additionally, it explored the effect of TMS to reduce premonitory ...
[56]
Effects of Low-Frequency Repetitive Transcranial Magnetic ...
Feb 12, 2021 · Low-frequency bilateral rTMS of the parietal cortex can markedly alleviate motor tics, phonic tics, and premonitory urges in patients with TS.
[57]
The Project Gutenberg eBook of Tics and Their Treatment, by Henry ...
Meige and Feindel have subjected their cases to the educational discipline of systematised movement and of immobilisation. In contrast to the tendency of ...
[58]
Premonitory urges are associated with decreased grey matter ...
Premonitory urges are associated with decreased grey matter thickness within the insula and sensorimotor cortex in young people with Tourette syndrome ... J ...
[59]
A Bayesian Account of the Sensory-Motor Interactions Underlying ...
Mar 5, 2019 · Clinically TS is characterised by the recurrent expression of tics, which are often preceded by premonitory sensations or urges, and are under ...
[60]
Effects of Low-Frequency Repetitive Transcranial Magnetic ...
Feb 11, 2021 · Low-frequency bilateral rTMS of the parietal cortex can markedly alleviate motor tics, phonic tics, and premonitory urges in patients with TS.