The guidelines offered by the New York State Workers Compensation Board present general principles for the use of medications in the context of brain injuries. These directives aim to assist healthcare professionals in determining appropriate pharmacological interventions as part of a comprehensive treatment plan.

Healthcare practitioners specializing in the medication management of brain injuries can depend on the guidance provided by the Workers Compensation Board to make well-informed decisions about the most suitable drugs for their patients.

It is crucial to emphasize that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding medication use for brain injuries should involve collaboration between the patient and their healthcare provider.

Medications for brain injury

Treating long-term post-traumatic issues often involves using medications. Administering drugs requires careful evaluation of the patient’s response, constant monitoring, and ongoing assessment of the treatment’s effectiveness. This involves reducing or stopping medications when symptoms get better and occasionally experimenting with lower doses when symptoms remain stable.

Relying solely on medications is unlikely to fully relieve symptoms. To minimize the need for medication in TBI patients, it’s crucial to combine non-drug interventions with pharmacological treatments. The main aim of drug therapy is to enhance the patient’s functionality. Managing post-traumatic deficits involves ongoing participation in suitable rehabilitative programs and utilizing techniques like cognitive rehabilitation, cognitive behavioral therapy, and other tailored physical and psychological practices, as explained elsewhere in this guideline.

When clinically warranted, prescription medications should undergo a proper trial to assess therapeutic effects and the individual’s tolerance. The duration of a suitable trial varies widely depending on the drug and the person’s response. Some medications, such as antidepressants, may take weeks to months to show efficacy, while others, like psychostimulants, might require only a few doses.

The drugs mentioned in the medication section are approved by the FDA for different purposes, but they can be appropriately used to address various aspects of TBI treatment and related conditions. When prescribing a medication for an off-label FDA use, it’s crucial to clearly outline the indications and set clinical and functional goals within a comprehensive, function-oriented treatment plan.

Patients recovering from a TBI are particularly sensitive to side effects affecting the central nervous system, such as sedation, dizziness, cognitive impairment, and motor issues. Typically, initial medication doses may need to be lower than usual, and adjustments should be made gradually based on clinical appropriateness. A thorough medication history is vital, considering that many medications carry potential side effects that could worsen TBI-related symptoms or mimic them, including headaches, dizziness, changes in vision or hearing, fatigue, and other issues.

For instance, benzodiazepines, tricyclics, and anticonvulsants may induce or exacerbate dizziness. It’s important to assess the temporal relationship between the onset of symptoms and the initiation or dosing of these medications.

 

Headaches

Headaches often manifest as a common physical symptom in individuals who have experienced a traumatic brain injury (whether mild, moderate, or severe). Post-traumatic headaches typically fall into two main patterns: (i) tension-type headaches, which include a cervicogenic component, and (ii) migraine headaches. Generally, the recovery from post-traumatic headaches following a mild TBI or concussion is swift, occurring within hours to days, and most headaches resolve within three months.

However, there are cases where headaches persist longer, known as persistent post-traumatic headaches. Managing chronic headaches requires long-term maintenance plans, and medications may be recommended for an extended period.

Understanding the primary clinical characteristics of posttraumatic headaches is crucial for devising effective strategies, both pharmacologic and nonpharmacologic, for managing them. Regardless of the chosen approach, intervening at the onset of a headache, rather than waiting for it to worsen, increases the likelihood of successful pain treatment. When it comes to pharmacologic interventions, they can be suitable for both treating and preventing headaches (prophylaxis). During the acute phase of posttraumatic headache management, it’s advisable to steer clear of narcotic analgesics if possible, and there should be special attention given to evaluating medication-overuse headaches.

Non-pharmacologic management options encompass educating individuals on lifestyle adjustments, engaging in physical therapy, incorporating cervical manipulation, exploring acupuncture, and considering cognitive-behavioral therapy (CBT).

 

Prophylactic Treatment

If someone is dealing with more than three tension headaches each week, it might be helpful to explore preventive therapy aimed at averting these headaches. When it comes to migraine headaches, if they happen more than once a week and prove to be disabling despite trying various immediate treatments, or if they start affecting work attendance and daily life, it’s worth considering interventions to decrease their frequency.

 

Non-Steroidal Anti-Inflammatory Medications

Suggested for managing headaches linked to traumatic brain injury (TBI). To minimize the risk of duodenal and gastric ulceration associated with NSAID use, it’s recommended to administer PPIs, H2 blockers, and sucralfate alongside these NSAIDs. However, it’s essential to note that this combination doesn’t affect potential cardiovascular complications.

It’s worth remembering that the chronic overuse of analgesics like NSAIDs or acetaminophen, especially when used daily, may exacerbate headaches and lead to a condition known as chronic daily headache or medication overuse/rebound headache. Fortunately, in many cases, headaches tend to improve after a period of discontinuing analgesic use.

 

Acetaminophen

Suggested for addressing headaches linked to traumatic brain injury (TBI), especially in patients with contraindications for NSAIDs. The recommended dose and frequency should align with the manufacturer’s guidelines and can be used on an as-needed basis. However, caution is advised as exceeding four grams per day may lead to hepatic toxicity. It’s important to note that the chronic overuse of analgesics like NSAIDs or acetaminophen, particularly when used daily, can worsen headaches and result in chronic daily headache or medication overuse/rebound headache. Fortunately, most cases see an improvement in headaches after a period of discontinuing analgesic use.

 

Utilizing Topical Drug Delivery

It’s advised to consider using topical drug delivery methods like capsaicin, topical NSAIDs (such as topical diclofenac), and topical salicylates (like methyl salicylate) for treating post-traumatic brain injury (TBI) headaches, especially in certain individuals. These applications are suitable for patients who may have difficulty with oral medications or prefer topical treatments over taking medications by mouth.

 

Triptans and Ergot Alkaloids:

For dealing with post-TBI migraine headaches, it’s recommended to explore the use of triptans and ergot alkaloids. This is particularly relevant for instances of post-TBI migraine headaches, and the frequency, dose, and duration should align with the recommendations provided by the manufacturer.

 

Anticonvulsant Medications:

Consider incorporating anticonvulsants, such as gabapentin, topiramate, or divalproex, for the prophylactic treatment of post-traumatic tension and migraine headaches.

 

Antidepressants:

In the context of post-traumatic headaches, it’s advisable to consider antidepressants, including tricyclic antidepressants, for their prophylactic treatment. This applies to both post-traumatic tension and migraine headaches.

 

Beta Blockers:

It’s recommended to consider Propranolol for the preventive treatment of tension and migraine headaches following a traumatic brain injury (TBI). This is specifically indicated for the prophylactic treatment of tension and migraine headaches post-TBI, with the frequency, dose, and duration aligning with the manufacturer’s guidelines.

 

Anti-Emetics:

In the context of post-traumatic headaches, the use of anti-emetics is recommended to address nausea and vomiting.

 

Botulinum Toxin Injections for Chronic Migraine Headaches:

It’s advised to selectively use Botulinum Toxin Injections for individuals dealing with chronic migraine headaches linked to TBI. This is particularly indicated for the treatment of chronic migraines associated with TBI, although it’s not typically the first line of treatment. Botox treatment has shown significant potential in reducing the frequency of migraines, their severity, and the usage of acute medications. The injections generally need to be repeated every three months, and the evaluation of target muscles, doses, and efficacy should be conducted regularly. Common formulations to consider include AbobotulinumtoxinA, onabotulinumtoxinA, and incobotulinumtoxinA.

 

Medications (Conditions other than Headache)

Non-Steroidal Anti-Inflammatory Medications:

It’s advised to use NSAIDs for treating musculoskeletal pain and controlling fever associated with TBI. To minimize the risk of duodenal and gastric ulceration linked to NSAID use, it’s recommended to administer PPIs, H2 blockers, and sucralfate alongside NSAIDs. However, it’s important to note that this combination doesn’t have an impact on potential cardiovascular complications.

 

Proton Pump Inhibitors (PPIs):

It’s recommended to use PPIs in conjunction with NSAIDs for certain TBI patients. This is particularly indicated for individuals using NSAIDs with risk factors for GI bleeding, such as the elderly, those with diabetes mellitus, or rheumatoid arthritis. The potential benefits include a decreased risk of GI bleeding from NSAIDs.

 

H2 Blockers:

Selective use of H2 blockers is recommended for treating TBI patients using NSAIDs with risk factors for GI bleeding, like the elderly, individuals with diabetes mellitus, or rheumatoid arthritis. The benefits encompass reducing the risk of GI bleeding from NSAIDs and may also decrease the risk of stress ulcers. The dosage and frequency for proton pump inhibitors, sucralfate, and H2 blockers should align with the recommendations provided by the manufacturer.

 

Sucralfate:

For the treatment of TBI patients, it’s recommended to use sucralfate, particularly in cases where NSAIDs are used with risk factors for GI bleeding, such as a past history of GI bleeding, being elderly, or having diabetes mellitus or rheumatoid arthritis. The potential benefits include a decreased risk of GI bleeding from NSAIDs. The dosage and frequency for proton pump inhibitors, sucralfate, and H2 blockers should align with the recommendations provided by the manufacturer.

 

Acetaminophen:

It’s recommended to use acetaminophen for managing musculoskeletal pain and controlling fever associated with traumatic brain injury (TBI), particularly in cases where NSAIDs are contraindicated. The dosage and frequency should align with the manufacturer’s recommendations and can be used on an as-needed basis. However, exceeding four grams per day has been linked to evidence of hepatic toxicity.

 

Topical Drug Delivery:

Employing topical drug delivery methods, such as capsaicin, topical NSAIDs (like topical diclofenac), and topical salicylates (such as methyl salicylate), is suggested for addressing musculoskeletal pain after TBI, especially in specific cases. These applications are suitable for patients who may have difficulty with oral medications or prefer topical treatments over taking medications by mouth.

 

Neurostimulants:

It’s recommended to consider neurostimulants for select TBI patients experiencing cognitive issues like problems with arousal, initiation, memory, and attention. Medications commonly used for this purpose include dopaminergic agents (such as amantadine, methylphenidate, bromocriptine, and carbidopa/levodopa), wake-promoting stimulants (like modafinil), and acetylcholinesterase inhibitors (such as donepezil). Initially, a six-week duration may be appropriate, with longer duration indicated for ongoing deficits provided there are ongoing cognitive improvements.

 

Anti-Spasticity Agents

The use of anti-spasticity agents is recommended for treating TBI patients dealing with muscle spasticity and hypertonia associated with TBI. Oral medications commonly used for this purpose include tizanidine, dantrium, and baclofen, with the dosage and frequency following the manufacturer’s recommendations.

 

Intrathecal Baclofen (ITB) Pump:

It’s recommended to highly selectively consider the use of the Intrathecal Baclofen (ITB) Pump for TBI patients. This is indicated for treating severe, chronic muscle spasticity and dystonia associated with TBI that can’t be adequately controlled through non-invasive methods, including other pharmaceutical options like baclofen at 80-160 mg/day. Patients should have tried and considered at least one of diazepam, clonidine, and/or dantrolene. Additionally, the hypertonia should be severe enough to interfere with daily activities. Generally, at least two trials of saline and an intrathecal dose of baclofen are conducted to confirm efficacy before contemplating the implantation of an intrathecal pump.

 

Botulinum Toxin Injections:

It’s recommended to selectively use Botulinum Toxin Injections for individuals dealing with chronic muscle spasticity or dystonia, particularly in patients with moderate-to-severe TBI. This is indicated for the treatment of chronic muscle spasticity or dystonia associated with TBI, especially when the patient cannot tolerate oral pharmaceutical agents, poor arousal prevents the use of oral agents, or the spasticity or dystonia is focal and would benefit from a targeted treatment plan. The injections typically need to be repeated every three months, with target muscles, doses, and efficacy reevaluated regularly. Common formulations to consider include AbobotulinumtoxinA, onabotulinumtoxinA, and incobotulinumtoxinA.

 

Antiseizure/Anticonvulsant:

Traumatic brain injuries often come with the frequent complication of posttraumatic seizures. To prevent early seizures, prophylactic antiseizure medications are generally recommended within the first seven days following a moderate to severe TBI associated with cerebral contusion or intracranial bleeding. These medications are also advised for treating and preventing the progression of the initial seizure, as well as reducing the risk of subsequent seizures after the first post-TBI seizure.

 

Antidepressants:

For TBI patients experiencing depressive symptoms or depression, the use of antidepressants is recommended for treatment.

 

Atypical Antipsychotics:

It’s suggested to consider atypical antipsychotics for adjunctive treatment of acute major depression (such as aripiprazole, brexpiprazole, cariprazine, olanzapine, quetiapine, risperidone, or ziprasidone). These may be effective for maintenance treatment. Additionally, they are recommended for addressing mood and behavioral disturbance post-TBI, as well as augmenting antidepressants in treating major depressive disorder associated with TBI. In select cases, they may be recommended for individuals with psychosis associated with TBI. Indications for the latter include the treatment of depressive disorders with psychotic characteristics, such as serious delusions, visual or auditory hallucinations, confusion, catatonic behavior, extreme negativism or mutism, peculiar movements, inappropriate affect of a bizarre or odd quality, and severe symptoms. It’s emphasized that second-generation antipsychotics should only be considered when other strategies have failed due to their significant side effects.

 

Benzodiazepines:

It’s recommended to consider benzodiazepines for treating TBI patients with indications for anxiety disorders, including panic attacks secondary to TBI. They are also suggested for addressing posttraumatic movement disorders and post-traumatic epilepsy in TBI patients. These can be utilized for discrete issues such as anxiety, panic attacks, agitation, and insomnia. However, it’s important to note that benzodiazepines can impair memory and cognitive recovery. Therefore, TBI patients requiring a course of benzodiazepines should be tapered as soon as practical.

 

Corticosteroids:

The use of corticosteroids is not recommended for treating TBI.

 

Excitatory Amino Acid Inhibitors:

It’s not recommended to use excitatory amino acid inhibitors for treating TBI.

 

Sedatives, Sedative Hypnotics:

The use of sedatives and sedative hypnotics is not recommended for treating TBI patients.

 

Beta Blockers:

Beta blockers are recommended for treating TBI patients and can be used for managing tachycardia, hypertensive management, and addressing paroxysmal sympathetic hyperactivity or agitation. The frequency, dose, and duration should align with the manufacturer’s recommendations.