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CME/CE: Neurology
The most effective treatment approach is thorough patient education about
concussion, the patient's particular findings, possible treatments and the
expectation for recovery.
Tools are available to assess symptoms
after a concussion. The Rivermead Post-
Concussion Symptom Inventory is a validated
tool that can be used to track the
course of symptoms, including impact
on the patient and his or her daily functioning
(http://www.tbi-impact.org/cde/
mod_templates/12_F_06_Rivermead.pdf). 20
Treatments
The most effective treatment approach
is thorough patient education about concussion,
the patient’s particular findings,
possible treatments and the expectation
for recovery. 21 This education should be
repeated at subsequent visits, due to the
short-term memory issues and anxiety
common in this population.
Typical areas to cover in patient education
include the natural history of mTBI
and expected recovery, sleep hygiene techniques,
the need for abstinence from drugs
and alcohol (which can increase symptoms
and decrease the brain’s ability to heal),
proper nutrition, coping strategies and
avoidance of repeat concussion. The dangers
of self-medication should be addressed,
since patients may try caffeinated beverages
to treat cognitive issues, alcohol or drugs
to help with sleep and anxiety, and OTC
medications to treat headaches or other
symptoms. Reinforce the need for rest and
Table 4
Additional Resources
avoidance of caffeine and alcohol, as well
as use of medications only as prescribed.
Using a medication organizer is one way
of ensuring the patient safely dispenses his
or her own medication in the right dosing
and time frame.
Until the patient has recovered, he or
she should not engage in activities that
will increase symptoms, such as mental
or physical exertion. Depending on home
and work status, specific guidance about
return to work or school may be necessary.
Start with a gradual increase in activity
and increase the amount of activity as
symptoms improve. 11 Driving, climbing
and operating heavy machinery are areas
of concern when visual, balance, cognitive
or coordination difficulties exist.
Cognitive functioning should return
to baseline about 7 days to 1 month after
mTBI. 21 Instruct the patient to follow up
in 1 week if symptoms are not improving.
Make a specialist referral for evaluation
of ongoing cognitive symptoms or other
symptoms that are severe, such as depression,
pain or post-traumatic stress. 22,23
These specialists may use neuropsychologic
testing to help determine when return
to work, school or play is appropriate. 24
The involvement of several medical and
complementary specialties may be necessary
to provide complete care. Depending
The Centers for Disease Control and Prevention operates a concussion resource
center at http://www.cdc.gov/Concussion/.
The Defense and Veterans Brain Injury Center website, www.DVBIC.org, provides
information for service members and their families, as well as for healthcare providers.
At this site, you can request a copy of the “Mild Traumatic Brain Injury Pocket Guide”
and other tools. These can also be downloaded to iPhones, iPads and devices that use
the Android platform.
The Veterans Administration and Department of Defense clinical practice guideline for
the management of mild traumatic brain injury is geared toward healthcare providers
within the VA/DoD healthcare setting, but it can be useful to providers in the civilian
setting. http://www.dvbic.org/pdf/VADoD-CPG---Concussion-mTBI.pdf
The American Association of Neuroscience Nurses and the Association of Rehabilitation Nurses developed
“Care of the Patient with Mild Traumatic Brain Injury.” This document can be downloaded at http://www.
rehabnurse.org/uploads/files/cpgmtbi.pdf
on the provider’s level of comfort and the
resources in the clinic, several symptoms
may be appropriate for treatment in primary
care. Adopt a “start low and go slow”
approach to any prescription medications.
After injury, the brain is more sensitive
to medication and therefore the risk of
side effects increases. 25
Headaches are often managed by primary
care providers, and in this patient
population headache would be a typical
symptom to treat. The cause of post-traumatic
headache is not completely understood,
but the treatments are aimed at the
type of headache that occurs: migrainous,
tension-type, cervicogenic, overuse/
rebound, chronic daily or combination.
Treatments for these headaches include
non-narcotic pain medications (avoiding
tramadol because it can increase seizure
risk), nonsteroidal anti-inflammatory
drugs, triptans, tricyclic antidepressants,
anti-epileptic drugs, beta-blockers, botulinum
toxin and occipital blocks. Referral to
a neurologist may be beneficial depending
on the experience of the clinician, the type
of headaches experienced and the response
to attempted treatments. Refer to a dentist
for evaluation of pain, popping or clicking
at the temporomandibular joint.
Sleep problems are common in patients
who have experienced a concussion. They
may report trouble getting to sleep, frequent
awakenings, nightmares or weird
dreams. Good sleep hygiene and the
incorporation of relaxation techniques
can be helpful. Trazodone is considered
first-line treatment for sleep disturbances
in patients recovering from concussion;
this is an off-label use. 26 The short-term
use of sleep aids such as zolpidem or
eszopiclone can provide quick results
for patients. Other possibilities are using
medications that will work on multiple
issues, such as a tricyclic antidepressant
that helps prevent headaches, increases
nighttime sleepiness and may improve
mood. It is important to avoid the use
of benzodiazepines because they may
interfere with neuronal recovery. 27 Referral
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