Medication

 
 

Medications for Concussion Symptoms - Introduction

Currently there is no medication designed specifically for concussions. Doctors typically will start talking to patients about medications when their concussion symptoms become persistent, for example, prescribing migraine medications for headache symptoms, SSRI's for depression symptoms, etc. Leading doctors in the field recommend that medication should not be prescribed in isolation, but with professional therapists (PT, OT) and lifestyle interventions. Some people are self-medicating with CBD oil from hemp or high CBD/low THC marijuana. Other patients are using over-the-counter medicine or caffeine in small doses for headaches. See below for further information.

Prescription Medications

Doctors may prescribe medications for symptoms such as pain, anxiety, insomnia, and depression. Dr. Chris Giza, Director of the Steve Tisch BrainSPORT Program at UCLA, recommends that concussion patients avoid taking medications that create problematic side effects, and that medications only be used in conjunction with professional therapies and lifestyle changes. 

The medications doctors may prescribe migraine medications for headaches; SSRI (serotonin reuptake inhibitors) for depression; amitriptyline or trazadone for insomnia; and valproic acid or gabapentin for mood stabilization.

A 2019 review of the management of post-concussion syndrome in children gives a detailed explanation of medications that are sometimes used for a variety of symptoms (including post-traumatic headache); we’ve republished this explanation at the bottom of this page. Also at the bottom of this page is a chart of medications and nutritional supplements prescribed for migraines.

The 2017 International Consensus on Concussion in Sport has this to say about medications for a concussion:

"Currently, there is limited evidence to support the use of pharmacotherapy. If pharmacotherapy is used, then an important consideration in return to sport is that concussed athletes should not only be free from concussion-related symptoms, but also should not be taking any pharmacological agents/medications that may mask or modify the symptoms of sport-related concussion. Where pharmacological therapy may be begun during the management of an sport-related concussion, the decision to return to play while still on such medication must be considered carefully by the treating clinician. Overall, these are difficult cases that should be managed in a multidisciplinary collaborative setting, by healthcare providers with experience in sport-related concussion."

Over-The-Counter Medications

There is concern about taking over-the-counter medications within a short time frame after a concussion because of the rare chance of bleeding in the brain. If you have a headache and you suspect a concussion,  the Mayo Clinic recommends acetaminophen (Tylenol and other brands) and recommends avoiding pain medications that thin the blood, such as aspirin or ibuprofen (Advil, Motrin IB, others), as they may increase the risk of bleeding.  

Other sources say not to take acetaminophen until four hours after the concussion and avoid medications such as Advil and Aleve (which thin the blood) for the first 12 hours of a concussion. We recommend that if your symptoms are worsening, go to the ER - if the doctors suspect bleeding in the brain they will do scans to rule out that possibility. 

Once any concern about a brain bleed is past, over-the-counter medications are okay to use for symptoms of a concussion.

The full range of over-the-counter pain medications is sometimes part of treatment for what is termed Post Traumatic Headache, also referred to as post-concussion syndrome. In many cases, the recommended dose of over-the-counter medications may be subtherapeutic (not strong enough) for post-concussion headaches. For example, the label on naproxen sodium  (ALEVE and generic formulations) says to take one tablet (220 mg) two times daily. "However, many clinical practitioners recommend approximately 500–550 mg of naproxen sodium per dose for headache treatment."

Be aware of the problems associated with NSAIDs (nonsteroidal anti-inflammatory drugs) such as ibuprofen, naproxen, celecoxib (Celebrex), meloxicam and aspirin. (Acetaminophen is not an NSAID). The recommended dosing on the labels may not be enough to help, and if you take too much, you've got another set of problems: "nonsteroidal anti-inflammatory drugs and aspirin can cause gastritis, gastrointestinal bleeding, increased bleeding time, and peptic ulcer disease." 

Even more of a concern, "The evidence has been building for years that NSAIDs are bad for the cardiovascular system. Epidemiological studies have suggested that such drugs increase the risk for heart attacks, strokes, congestive heart failure and death."

Melatonin

Melatonin is produced in the body and can be supplemented with over-the-counter liquid or tablet melatonin. Melatonin acts in the body in ways that supports recovery from TBI, including decreasing neuroinflammation, reducing oxidative stress, improving mitochondrial function, and decreasing glutamate toxicity. It also has therapeutic properties; research has shown it to reduce chronic pain, migraines headaches, and anxiety. Research in Canada has found that "children with prolonged PCS and headaches had a significant response to melatonin treatment," especially for Post-traumatic headaches which are considered particularly resistant to treatment. Current trials with children and PCS headaches are using 3 mg and 10 mg doses of Melatonin.

CBD products

Some professional athletes, veterans, and patients with Post-Concussion Syndrome are self-medicating with CBD products (either from hemp or marijuana) which have little or no THC, so they don't get you high. There is considerable anecdotal evidence that CBD products are helpful for headaches, insomnia, and anxiety. Our section CBD covers the research concerning CBD. Also, see the article "Why Athletes are Ditching Ibuprofen for CBD."

Caffeine

WebMD says that caffeine can help headaches by reducing inflammation, and ingesting caffeine along with aspirin, ibuprofen, or acetaminophen makes these over-the-counter medications work faster, better, and keep the pain away for longer.

Warning:

  • Withdrawal from daily use of caffeine (even as little as one cup a day) can cause a headache.

  • Medication over-use. If you take too much of any kind of pain reliever or take it too often, you can get a rebound headache when the meds wear off, and caffeine can make a rebound headache more likely. WebMD

From a 2019 study of management of post-concussion syndrome in children, regarding medication

Treatment of headaches after a concussion, also called post-traumatic headaches (PTH)

PTH are one of the most common complaints in patients with persistent symptoms after an acute concussion. Persistent PTH are defined as headaches lasting more than 3 months post-injury and often present as migraine or tension-type headaches [9••, 10]. Pre-existing history or profile for migraines or mood disturbance may increase the risk of development of PTH. In addition to a detailed headache history, it is important to screen for medication overuse headaches (MOH). Up to 70% of adolescents with chronic PTH meet the criteria for MOH [1112]. There are no established guidelines for the management of pediatric PTH and no high-quality studies comparing medication efficacy in PTH. A systematic review published in 2012 found there was insufficient evidence to recommend any specific pharmacological intervention for PTH [13].

Management of PTH is typically extrapolated from the management of a primary headache disorder with lifestyle modifications focusing on sleep hygiene, hydration, exercise, avoidance of triggers, stress management, and use of preventative and abortive medications.

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, are often initially used with variable results. If there is an insufficient response to NSAIDS and the headaches have migranous features, serotonin agonists (triptans) are often used and typically well tolerated in children [8•]. The American Academy of Neurology recommends consideration of preventative medications when headaches are occurring more frequently than twice per week.

In a retrospective review of adolescents at a regional concussion clinic, 82% of patients noted a benefit from the use of amitriptyline [14]. Some studies have shown good therapeutic benefits and long-term benefits from the use of a local anesthetic nerve block of the scalp [1416]. There is emerging data on the use of melatonin for the treatment of persistent PTH [9••] as well as a migraine preventative [17]. Vitamin B2 (riboflavin) has been shown to be an effective prophylactic treatment for migraine headaches [1819], which has sometimes been extrapolated to PTH as well. Other nutraceuticals, including high-dose magnesium and coenzyme Q-10, have some evidence in prophylaxis of migraine headaches, but there are no properly designed and powered clinical trials in the pediatric concussion population [2022]. Opiate use is not indicated for the treatment of pediatric headaches [11].

Cognitive behavioral therapy instead of, or in addition to medication

There is a fund of research on the effectiveness of cognitive behavioral therapy (CBT) for pediatric pain and injury for both youths and adults [55•, 56]. CBT has been shown to reduce pain frequency and severity, reduce associated stress, anxiety and depression, improve sleep, and improve functioning across domains, including school and physical activity [57, 58]. Recent research specifically supports the effectiveness of CBT for pediatric headache [59, 60]. As headaches are a predominant symptom in pediatric PCS, behavioral treatments may enhance or replace pharmacotherapy, with the advantage of eliminating dangerous side effects and reducing costs [61•]. As CBT targets both physical and emotional components of PCS, it is a particularly robust intervention, as premorbid and comorbid issues like anxiety and poor emotional awareness are shown to maintain and prolong PCS symptoms [2••, 62]. These confounding issues may create a psychological predisposition for the development of persistent PCS symptoms after an mTBI [63].

Pharmacological Treatment of Neurocognitive Symptoms

Cognitive deficits, especially in the domains of attention, concentration, and distractibility, are quite common in PCS. These symptoms do resemble those seen in ADHD and there has been some limited evidence showing the benefits of stimulants in PCS. A recent review of the literature found nine such studies with three of them focused on children. There was limited evidence that immediate release methylphenidate had some positive impact in the domains of attention, fatigue, and depression [49•]. Although not specifically a stimulant, amantadine is thought to potentiate dopamine, giving it a stimulant-like effect. One small cohort study of adolescents with PCS found that the use of amantadine improved symptoms and cognitive performance when compared to historical controls [50]. There is little to no evidence supporting the use of nutraceuticals for cognitive deficits in PCS.

Pharmacological Treatment of Emotional Symptoms

In addition to appropriate psychotherapy including CBT, some patients may benefit from pharmacological management of mood symptoms. It is critical to gather a thorough psychiatric history including prior psychiatric diagnosis and treatments, family history, and current symptoms. It is also important to separate severity of symptoms from a normal response to a stressor, such as having a phobia of driving a car after a motor-vehicle accident to a psychiatric DSM diagnosis such as post-traumatic stress disorder. Tools, such as the Beck Depression Inventory-II, Patient Health Questionnaire, or Brief Symptom Inventory-18, may help to define prior history of depression, anxiety, and somatization affecting protracted recovery after a concussion [2].

Antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs), have become a primary treatment for concussion-related mood symptoms because of perceived clinical efficacy and relatively few side effects. The evidence is fairly limited and mostly extrapolated from a more severe TBI population. There is some evidence that SSRIs reduced depression symptoms and cognitive impairments after mTBI [8182]. Other antidepressants, including those with a mixture of effects on serotonin, norepinephrine, and dopamine, have little to no evidence for treatment of post-concussion depression [83]. In addition to the prior-mentioned melatonin, Trazodone is often used in the brain-injured population to treat sleep disorders in the acute phase after TBI [84].

Review of the Management of Pediatric Post-Concussion Syndrome—a Multi-Disciplinary, Individualized Approach, Mitul Kapadia et al.

Medications and Nutritional Supplements Used in Headache (Migraine) Treatment

 
 

Chart is from Brain Neurotrauma: Molecular, Neuropsychological and Rehabilitation Aspects by Sylvia Lucas. Preventive treatment is headache treatment that is used daily when attack frequency is high. 

Future Medications Specifically for Concussions

In the future, there will be medications specifically for concussions, both for initial treatment right after the concussion, and for those with Post-Concussion Syndrome.

We know of two different concussion medications which are in clinical trials. The University of Miami, funded by a Canadian R&D firm, is in pre-clinical studies of a medication that combines CBD (cannabidiol) and another chemical, for use both right after a concussion and long-term symptoms. See our section on CBD from Marijuana or Hemp

Oxeia Biopharmaceuticals Inc is developing a medication based on synthetic human ghrelin (OXE-103) and is in Phase 2 studies as of 2018. The medication is intended to address the brain's metabolic "energy crisis" as it responds to the concussion, with the aim of lessening metabolic dysfunction and therefore longer-term consequences of concussions. Chris Nowinski, Ph.D., CEO of the Concussion Legacy Foundation, is an advisor to Oxeia.