Home > Concussion / Mild TBI > Repetitive Head Injury Syndrome

Email Print Share

Repetitive Head Injury Syndrome David Cifu, MD, eMedicine.com (page 5 of 8) Page 5 of 8

Drug Category: CNS Stimulants

Central nervous system (CNS) stimulants are used to treat the hypoarousal and poor initiative often seen in patients with brain injuries.
Drug Name: Methylphenidate (Ritalin, Ritalin SR)
Description: 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.

Adult Dose: 5 mg PO bid initially; can be increased 5 mg/d; not to exceed 20 mg PO bid
Pediatric Dose: 5 mg PO bid initially; can be increased 5 mg/d; not to exceed 10-15 mg PO bid
Contraindications: Documented hypersensitivity; glaucoma; Tourette syndrome
Interactions: Reduces the effects of guanethidine and bretylium; may increase the toxicity of concurrent phenytoin, TCAs, warfarin, primidone, and phenobarbital; MAOIs increase toxicity
Pregnancy: C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions: Caution in patients with dementia, seizures, and hypertension; monitor patient's BP and heart rate

Drug Category: Anti-Parkinson agents
Anti-Parkinson medications have been useful in patients with brain injuries because these drugs increase their arousal and attention to tasks.
Drug Name: Amantadine (Symmetrel)
Description: 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.
Adult Dose: 100 mg PO bid initially; increase to 150 mg PO bid if no or minimal response
Pediatric Dose: Not established
Contraindications: Documented hypersensitivity
Interactions: Drugs with anticholinergic or CNS-stimulating activity increase toxicity; concurrent administration of hydrochlorothiazide plus triamterene may increase plasma concentrations
Pregnancy: C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions: Caution in patients with liver disease, uncontrolled psychosis, eczematoid dermatitis, seizures, and in those who have use of CNS stimulants; reduce dose in the presence of renal disease when treating Parkinson disease; do not discontinue abruptly

Drug Name: Carbidopa/levodopa (Sinemet)
Description: May increase alertness and attention to task in patients with brain injury.
Adult Dose: 1 tab (10 mg/100 mg) PO tid initially; increase to effect q3d; not to exceed 4 tabs (25/250) PO tid
Pediatric Dose: Not established
Contraindications: Documented hypersensitivity; narrow-angle glaucoma; malignant melanoma; undiagnosed skin lesions
Interactions: Hydantoins, pyridoxine, phenothiazine, and hypotensive agents may decrease effects; toxicity increases with antacids and MAOIs
Pregnancy: C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions: Adverse CNS effects (eg, dyskinesias) may occur at lower doses and earlier in therapy with the SR form; caution in patients with a history of myocardial infarction, arrhythmias, asthma, and peptic ulcer disease; sudden discontinuation may cause worsening of Parkinson disease; high-protein foods should be distributed throughout the day to avoid fluctuations in levodopa absorption

Drug Category: Central Nervous System Stimulant, Nonamphetamine
Nonamphetamine CNS agents have actions that are similar to sympathomimetic agents.
Drug Name: Modafinil (Provigil)
Description: 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.
Adult Dose: 200 mg/d PO in am; may increase to 400 mg/d
Pediatric Dose: <16 years: Not established >16 years: Administer as in adults
Contraindications: Documented hypersensitivity
Interactions: May decrease the levels of cyclosporine or steroidal contraceptives, and to a lesser degree, theophylline; modafinil may increase the drug concentration levels of diazepam, propranolol, and phenytoin
Pregnancy: C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions: Monitor patients closely for signs of misuse or abuse, especially those with a history of drug or stimulant abuse, such as methylphenidate, amphetamine, and cocaine; leukopenia has been reported in pediatric patients; may cause serious life-threatening rash (ie, Stevens-Johnson Syndrome, toxic epidermal necrolysis, drug rash with eosinophilia and systemic symptoms), hypersensitivity reactions (eg, angioedema, multiorgan reactions), and psychiatric symptoms (eg, anxiety, mania, hallucinations, suicidal ideation)

Follow-Up

Return to Play

No good parameters have been proposed for repetitive head injury. As a result, most physicians use the parameters for concussion. The following systems present two options for concussion management, although many options are available. Note that in the following descriptions, asymptomatic means that the patient is symptom free at rest and with exertion.

From eMedicine.com. Reprinted with permission. www.emedicine.com/sports/TOPIC113.HTM.

 Comments [2]