Medication Summary

Care should be used when instituting therapy with medications that potentially have sedating effects, because sedation may complicate the monitoring of a patient with a brain injury. Some medications that can have significant sedating effects on such patients include H2 blockers (eg, ranitidine, famotidine), diphenhydramine, narcotic pain relievers, nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, antipsychotics, and seizure medications.

Some medications may improve the patient's focus and alertness. A few of these medications are discussed below. In addition to the agents that may enhance thinking skills, aggressive management of specific symptoms is also warranted, including insomnia (trazodone), headaches (butalbital, aspirin, and caffeine [Fiorinal]; isometheptene mucate, dichloralphenazone, and acetaminophen [Midrin]; acetaminophen; NSAIDs; local agents), dizziness (meclizine, buspirone, vestibular programs, liberatory technique), and depression (cognitive behavioral therapy, selective serotonin reuptake inhibitors [SSRIs]).

Class Summary

Central nervous system (CNS) stimulants are used to treat the hypoarousal and poor initiative often seen in patients with brain injuries.

Methylphenidate (Ritalin, Ritalin SR)

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Although most notably used in children with attention-deficit/hyperactivity disorder (ADHD), this agent often helps with hypoarousal. Frequently the first drug used in patients with brain injury.

Not used as often in children with brain injury; when used, administer as in children with ADHD.

Administered in morning and at noon before a therapy session to facilitate stimulant effect and increase attention to tasks. If no response is achieved, can be discontinued and another medication can be used.

Class Summary

Anti-Parkinson medications have been useful in patients with brain injuries because these drugs increase their arousal and attention to tasks.

Amantadine (Symmetrel)

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Unknown mechanism of action; may release dopamine from remaining dopaminergic terminals in patients with Parkinson disease or from other central sites. Less effective than levodopa in treating Parkinson disease; slightly more effective than anticholinergic agents.

Carbidopa/levodopa (Sinemet)

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May increase alertness and attention to task in patients with brain injury.

Class Summary

Nonamphetamine CNS agents have actions that are similar to sympathomimetic agents.

Modafinil (Provigil)

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May exert stimulant effects by decreasing GABA-mediated neurotransmission. Has wake-promoting actions similar to sympathomimetic agents. Improves wakefulness in patients with excessive daytime hypersomnolence. Has been used in narcolepsy and primary hypersomnia. Mechanism of action is unclear.

Follow-up

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Author

David Xavier Cifu, MD The Herman J Flax, MD, Professor and Chairman, Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University School of Medicine; National Director, PM&R Services, Department of Veterans Affairs

David Xavier Cifu, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Brain Injury Association of America, American Congress of Rehabilitation Medicine, American Medical Association, Association of Academic Physiatrists, National Stroke Association

Disclosure: Nothing to disclose.

Coauthor(s)

David F Drake, MD Bavaria MEDDAC Medical Evaluation Board Physician, Physical Medicine and Rehabilitation/Pain and EMG Consultant

David F Drake, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Physiatric Association of Spine, Sports and Occupational Rehabilitation, American College of Sports Medicine, International Society of Physical and Rehabilitation Medicine

Disclosure: Nothing to disclose.

Brian D Steinmetz, DO Resident, Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University

Brian D Steinmetz, DO is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Osteopathic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Institute of Ultrasound in Medicine, International Spine Intervention Society, North American Spine Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Lipogems.

Acknowledgements

Invaluable assistance in the preparation of this manuscript was received from Ingrid A. Prosser, MD.

Sections Repetitive Head Injury Syndrome
Overview
Presentation
DDx
Workup
Treatment
Guidelines
Medication
Follow-up
References

Repetitive Head Injury Syndrome Medication

Medication Summary

CNS Stimulants