What is the first line of treatment for a patient with concussion, insomnia, loss of smell (anosmia), and loss of taste (ageusia)?

Treatment for Post-Concussion Syndrome with Insomnia, Anosmia, and Ageusia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for patients with post-concussion syndrome experiencing insomnia, while addressing anosmia and ageusia requires primarily supportive care as there are no established treatments for post-traumatic smell and taste loss. 1, 2, 3

Management of Post-Concussion Insomnia

First-Line Treatment: CBT-I

• CBT-I has demonstrated efficacy specifically for post-concussion insomnia and should be initiated before considering medications 2
• Components of CBT-I include:
  • Stimulus control (using bed only for sleep)
  • Sleep restriction therapy (limiting time in bed)
  • Relaxation training
  • Cognitive therapy (addressing unrealistic beliefs about sleep)
  • Sleep hygiene education 1
• A recent randomized controlled trial showed that CBT-I not only improves sleep outcomes in concussion patients but also reduces overall post-concussion symptom severity 2

Second-Line Treatment: Pharmacotherapy

If CBT-I is ineffective after 4-8 weeks, consider pharmacotherapy:

• For sleep onset insomnia: ramelteon (8mg), zolpidem (10mg, 5mg for elderly), or zaleplon (10mg) 1
• For sleep maintenance insomnia: low-dose doxepin (3-6mg), eszopiclone (2-3mg), or suvorexant (10-20mg) 1

Caution: Avoid benzodiazepines when possible as they may worsen cognitive symptoms in concussion patients and carry risk of dependence

Management of Post-Concussion Anosmia and Ageusia

Diagnostic Workup

• MRI of the brain is recommended to evaluate for:
  • Frontal lobe injury
  • Damage to olfactory bulbs/tracts
  • Lesions in olfactory sulcus 4, 5

Treatment Approach

• Currently, there are no established pharmacological treatments with proven efficacy for post-traumatic anosmia or ageusia 6, 7
• Weak recommendations based on limited evidence include:
  • Early information and advice about potential recovery patterns
  • Graded physical exercise program
  • Vestibular rehabilitation if dizziness is present
  • Manual treatment of neck and back if concurrent cervical injury
  • Psychological treatment for emotional symptoms
  • Interdisciplinary coordinated rehabilitative treatment 3

Comprehensive Management Plan

1. Week 1-2:

   • Begin CBT-I sessions (in-person or via telehealth)
   • Obtain MRI of brain to assess olfactory structures and rule out treatable causes
   • Provide education about expected recovery patterns

2. Week 3-6:

   • Continue CBT-I
   • Implement graded physical exercise program starting with low intensity and gradually increasing
   • Consider referral to ENT specialist for formal olfactory testing

3. Week 7-8:

   • Assess response to CBT-I
   • If insomnia persists, consider adding appropriate pharmacotherapy based on insomnia type
   • Continue supportive care for anosmia/ageusia

4. Follow-up:

   • Schedule follow-up within 2-4 weeks after initiating any treatment to evaluate effectiveness 1
   • Monitor for improvement in sleep parameters and post-concussion symptoms
   • Consider referral to a specialized concussion clinic if symptoms persist beyond 12 weeks

Important Considerations

• Post-traumatic anosmia and ageusia may persist long-term or be permanent in some cases, especially with significant frontobasal brain damage 7
• Zinc deficiency has been observed in patients with post-traumatic taste and smell disorders, though supplementation efficacy is not well established 6
• Patients may experience parosmia (distorted smell) or phantosmia (phantom smells) during recovery phase 5
• Improvement in sleep has been shown to correlate with improvement in overall post-concussion symptoms 2