Psychiatrist.comPharmacologic Management of the Sequelae of Traumatic Brain Injuries

Pharmacologic and Non-Pharmacologic Approaches to Managing Cognitive and Behavioral Sequelae of Traumatic Brain Injury

Traumatic brain injury (TBI) often results in a range of cognitive and behavioral sequelae that can significantly impact patients’ quality of life. This comprehensive review examines the pharmacologic management of post-TBI symptoms, including impaired attention, concentration, aggression, and sleep disturbances. The article presents a tiered approach to medication selection, discusses non-pharmacologic interventions, and provides practical guidance for clinicians managing patients with TBI.

Key Points:

• Cognitive complaints, including difficulties with attention, concentration, and memory, are common after TBI.
• Methylphenidate and dextroamphetamine-amphetamine are first-line medications for impaired attention and concentration post-TBI.
• Amantadine has the most support for improving cognitive impairment after TBI.
• Acetylcholinesterase inhibitors, such as donepezil, may improve cognitive function and communication in TBI patients.
• Modafinil and armodafinil can improve wakefulness and alertness in TBI patients with excessive daytime sleepiness.
• Antidepressants like vortioxetine may benefit patients with comorbid depression and cognitive dysfunction post-TBI.
• Over-the-counter supplements like citicoline and S-adenosylmethionine (SAMe) show potential benefits for memory and brain function after TBI.
• Melatonin has been associated with improved sleep quality and reduced anxiety and fatigue in TBI patients.
• Cognitive behavioral therapy for insomnia (CBTi) and image rehearsal therapy (IRT) are effective non-pharmacologic interventions for sleep disturbances post-TBI.
• Cognitive rehabilitation interventions have shown substantial evidence for improving neurocognitive impairment and functional limitations in TBI patients.
• When prescribing medications for TBI patients, clinicians should consider the risk of lowering seizure threshold, especially in patients with a history of seizures.
• Cardiac risk factors should be assessed before prescribing stimulants or other medications that may affect cardiovascular function.
• A tiered approach to medication selection is recommended, starting with well-studied options and progressing to less-established treatments as needed.
• Combination therapies, such as pharmacologic interventions with cognitive rehabilitation or CBTi, may provide synergistic benefits.
• Regular monitoring for side effects and adjusting treatment plans accordingly is crucial in managing TBI patients.

“Although most patients with mTBI fully recover, a minority report continued psychiatric and neurological complaints. The persistence of postconcussive symptoms including headaches, nausea, fatigue, irritability, and cognitive complaints greater than 90 days is nonspecific and may not be directly attributable to the concussion or may be associated with co-occurring or preexisting conditions such as depression, PTSD, insomnia, alcohol or substance use disorders, or pain.”

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