Head Injury Medication

Head Injury Medication
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http://emedicine.medscape.com/article/1163653-medication
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Author: David A Olson, MD; Chief Editor: Stephen A Berman, MD, PhD, MBA more...
Updated: Apr 1, 2013
Medication Summary
Medications commonly are used in the acute setting to control early seizures, reduce intracranial pressure, and correct
electrolyte abnormalities. Nimodipine may be neuroprotective in the subset of patients with traumatic subarachnoid
hemorrhages.
In the long-term setting, cognitive and motoric augmentation as well as the control of spasticity and emotional
incontinence may require pharmacologic interventions.
Osmotic diuretics
Class Summary
These agents may help reduce intracranial pressure.
View full drug information
Mannitol (Osmitrol, Resectisol)

May reduce subarachnoid space pressure by creating osmotic gradient between CSF in arachnoid space and plasma.
Not for long-term use. Initially assess for adequate renal function in adults by administering test dose of 200 mg/kg,
given IV over 3-5 min; should produce urine flow of at least 30-50 mL/h of urine over 2-3 h. Same test in children
should produce urine flow of at least 1 mL/kg/h over 1-3 h.
Anticonvulsants
Class Summary
These agents may help prevent early seizures in head injury.
Phenytoin (Dilantin)
May act in motor cortex, where it may inhibit spread of seizure activity; activity of brainstem centers responsible for
tonic phase of grand mal seizures also may be inhibited.
Individualize dose. Administer larger dose in evening if dose cannot be divided equally.
Electrolytes
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Class Summary
Magnesium is given in hypomagnesemic states to ensure that adequate stores are present during acute phase of
head injuries.
Magnesium sulfate
Nutritional supplement in hyperalimentation; cofactor in enzyme systems involved in neurochemical transmission and
muscular excitability. In adults, 60-180 mEq of potassium, 10-30 mEq of magnesium, and 10-40 mmol of phosphate
per day may be necessary for optimum metabolic response.
Barbiturates
Class Summary
These agents may help reduce intracranial pressure that is refractory to other conventional measures.
Pentobarbital (Nembutal)
Short-acting barbiturate with sedative, hypnotic, and anticonvulsant properties. Can produce all levels of CNS
depression.
Calcium Channel Blocker

Class Summary
Nimodipine has been demonstrated to improve outcomes of patients with traumatic subarachnoid hemorrhages.
Nimodipine (Nimotop)
Indicated for improvement of neurological impairments resulting from spasms following subarachnoid hemorrhage
caused by ruptured congenital intracranial aneurysm in patients who are in good neurological condition postictus.
While studies show benefit on severity of neurological deficits caused by cerebral vasospasm following subarachnoid
hemorrhage, no evidence that drug either prevents or relieves spasms of cerebral arteries. Thus, actual mechanism of
action unknown.
Therapy should start within 96 h of subarachnoid hemorrhage. If capsule cannot be swallowed because patient
undergoing surgery or unconscious, a hole can be made at both ends of capsule with 18-gauge needle and contents
extracted into a syringe. Contents then can be emptied into patients' in situ nasogastric tube and washed down tube
with 30 mL isotonic saline.
Stimulants
Class Summary
These agents may help increase alertness and some aspects of cognitive functioning in patients with brain injury.
Methylphenidate (Ritalin)
Stimulates cerebral cortex and subcortical structures.
Dopamine agonist
Class Summary
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These agents may increase alertness in patients with brain injury; also may help in occasional patients with
posttraumatic parkinsonism.
Levodopa (Dopar, Larodopa)

Large neutral amino acid absorbed in proximal small intestine by saturable carrier-mediated transport system.
Absorption decreased by meals, which include other large neutral amino acids. Only patients with meaningful motor
fluctuations need consider low-protein or protein-redistributed diet. Greater consistency of absorption achieved when
levodopa taken 1 h or more after meals. Nausea often reduced if levodopa taken immediately following meals. Some
patients with nausea benefit from additional carbidopa in doses up to 200 mg/d. Half-life of levodopa/carbidopa
approximately 2 h.
When more carbidopa required, substitute 1 25/100 tab for each 10/100 tab; when more levodopa required, substitute
25/250 tab for 25/100 or 10/100 tab.
Sustained release (SR) formulation of levodopa/carbidopa is absorbed more slowly and provides more sustained
levodopa levels than immediate release (IR) dosage form; SR as effective as IR formulation when levodopa initially
required and may be more convenient when fewer intakes are desired.
Patients with dissipating motor fluctuations and no dyskinesia often benefit from prolongation of short-duration
response when switched from IR to SR; however, patients with meaningful fluctuations and dyskinesia often
experience increase in dyskinesia when switched to SR formulation.
Doses and dosing intervals of SR form may be increased or decreased based on response; most patients have been
treated adequately with 2-8 tab/d (divided doses) at intervals of 4-8 h while awake; higher doses (>12 tab/d) and
intervals < 4 h have been used but usually are not recommended; if < 4-h interval used or if divided doses are not
equal, give smaller doses at end of day. Allow at least a 3-d interval between dosage adjustments. May administer as
whole or half tab, which should not be crushed or chewed.
Selective serotonin reuptake inhibitors

Class Summary
These agents have been of benefit in patients with head injuries and emotional incontinence.
Sertraline (Zoloft)
Selectively inhibits presynaptic serotonin reuptake.
Antispasticity medications
Class Summary
These agents may reduce painful cramping and detrimental muscle tightening.
Tizanidine hydrochloride (Zanaflex)

Centrally acting muscle relaxant metabolized in liver and excreted in urine and feces.
Baclofen (Lioresal)
May induce hyperpolarization of afferent terminals and inhibit both monosynaptic and polysynaptic reflexes at spinal
level.
Dantrolene (Dantrium)
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Stimulates muscle relaxation by modulating skeletal muscle contractions at site beyond myoneural junction and acting
directly on muscle.
Diazepam (Valium)
Depresses all levels of CNS, possibly by increasing activity of GABA. Individualize dosage and increase cautiously to
avoid adverse effects.
Contributor Information and Disclosures

Author
David A Olson, MD Clinical Neurologist, Dekalb Neurology Group, Decatur, Georgia
David A Olson, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.
Specialty Editor Board
Joseph Carcione Jr, DO, MBA Consultant in Neurology and Medical Acupuncture, Medical Management and
Organizational Consulting, Central Westchester Neuromuscular Care, PC; Medical Director, Oxford Health Plans
Joseph Carcione Jr, DO, MBA is a member of the following medical societies: American Academy of Neurology
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College
of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
Florian P Thomas, MD, MA, PhD, Drmed Director, Regional MS Center of Excellence, St Louis Veterans Affairs
Medical Center; Director, National MS Society Multiple Sclerosis Center; Director, Neuropathy Association Center of
Excellence, Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular
Virology, St Louis University School of Medicine
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Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of
Neurology, American Neurological Association, American Paraplegia Society, Consortium of Multiple Sclerosis
Centers, National Multiple Sclerosis Society, and Sigma Xi
Chief Editor
Stephen A Berman, MD, PhD, MBA Professor of Neurology, University of Central Florida College of Medicine
Stephen A Berman, MD, PhD, MBA is a member of the following medical societies: Alpha Omega Alpha, American
Academy of Neurology, and Phi Beta Kappa
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