The premonitory urge is an unpleasant, internal sensory feeling that precedes the execution of a tic or movement. It serves as a warning signal that a tic is about to occur. The urge is a localized sensation of tension or discomfort that builds until the movement is performed, making the tic itself a response to an internal, aversive state. The primary goal of many treatments is to address this sensation directly.
The Subjective Experience of the Urge
The urge is often described as an irresistible feeling of pressure, tension, or discomfort that must be relieved. The specific manifestations are highly individualized but frequently include localized feelings such as a burning sensation, an itch, a tickle, or a vague sense of “rightness” that is unfulfilled. For instance, a person with a neck tic might feel a mounting tension in their shoulders that can only be temporarily resolved by shrugging.
The urge is a palpable bodily sensation, commonly occurring in the exact anatomical location where the subsequent tic will manifest. It starts subtly and then increases in intensity, similar to the escalating feeling before a sneeze or a cough. Performing the motor or vocal tic provides immediate, albeit transient, relief from this mounting discomfort, which reinforces the tic behavior over time.
The Neurological Basis
The generation of the premonitory urge is linked to dysfunction within the brain’s cortico-striatal-thalamo-cortical (CSTC) circuits, which regulate motor control and habit formation. These circuits are thought to have impaired inhibitory mechanisms. This failure in inhibition leads to an inappropriate build-up of motor readiness, which is subjectively experienced as the premonitory urge.
Key brain regions implicated in processing these urges include the supplementary motor area (SMA) and the insula. The insula is particularly involved in interoception—the sense of the body’s internal state—and its abnormal connectivity may contribute to the aversive, bodily nature of the urge. Neurotransmitter systems, particularly those involving dopamine, are also central to this dysfunction, as alterations in dopamine transmission within the basal ganglia are strongly associated with both tic generation and the severity of the urges.
Therapeutic Strategies for Coping
Managing the premonitory urge is a primary goal in treating tic disorders, using both behavioral and pharmacological interventions. Comprehensive Behavioral Intervention for Tics (CBIT) is a first-line, non-medication treatment that directly targets the urge-tic cycle. CBIT is built upon Habit Reversal Training (HRT), which involves two core components: awareness training and competing response training.
Awareness training teaches the individual to precisely identify the subtle, early signals of the premonitory urge, often by rating its intensity on a scale. This increased awareness creates an opportunity to intervene before the tic is executed. Competing response training teaches the person to perform a specific, voluntary movement that is physically incompatible with the impending tic. For example, if the urge precedes a shoulder shrug, the competing response might be to press the hands down firmly on the lap until the urge subsides.
This replacement behavior breaks the negative reinforcement loop where the tic provides relief, weakening the association between the urge and the tic over time. Pharmacological strategies aim to reduce the overall frequency and intensity of tics, which lessens the severity of the urges. Medications that modulate dopamine activity, such as certain dopamine receptor blockers, are frequently used. Other treatments, including botulinum toxin injections for localized tics, can also reduce both the tic and the corresponding urge.