What oral medications can be used to treat acute symptoms of headache, nausea, and tinnitus in post-concussive syndrome?

Oral Medications for Post-Concussive Syndrome Symptoms

For acute symptoms of post-concussive syndrome, use NSAIDs for headache, ondansetron for nausea, and amitriptyline for both headache and tinnitus as first-line treatments. 1, 2

Medication Approach by Symptom

Headache Management

1. First-line treatment:

   • NSAIDs (ibuprofen, naproxen) - limit to ≤15 days/month to prevent medication overuse headache 1
   • Acetaminophen - particularly safe option with fewer side effects

2. For persistent or severe headaches:

   • Triptans (sumatriptan) combined with NSAIDs - most effective for breaking severe headache attacks 1
   • Limit triptans to ≤10 days/month to prevent medication overuse headache 1

3. Preventive options (if headaches are frequent):

   • Amitriptyline (30-150 mg/day) - effective for both headache prevention and may help with tinnitus 1
   • Propranolol (80-240 mg/day) - effective first-line agent for headache prevention 1
   • Topiramate (100 mg/day) - effective but may cause cognitive side effects which could worsen post-concussive symptoms 1

Nausea Management

1. First-line treatment:

   • Ondansetron (8 mg twice daily) - highly effective for nausea control with minimal sedation 2
   • Dosing: 8 mg tablet taken twice daily as needed for nausea

2. Alternative options:

   • Promethazine or prochlorperazine - effective but may cause sedation
   • Metoclopramide - can help with both nausea and headache but watch for extrapyramidal side effects

Tinnitus Management

1. First-line treatment:

   • Amitriptyline (10-25 mg at bedtime, gradually increasing to 30-150 mg/day as tolerated) 1
   • May address both tinnitus and headache symptoms simultaneously

2. Alternative options:

   • Nortriptyline - similar to amitriptyline with potentially fewer side effects
   • Anticonvulsants (gabapentin) - may help with tinnitus in some patients

Treatment Algorithm

1. Initial approach:

   • Start with NSAIDs or acetaminophen for headache
   • Add ondansetron 8 mg twice daily for nausea 2
   • If symptoms persist beyond 2 weeks or are severe from onset, consider adding amitriptyline starting at low dose (10-25 mg at bedtime) 1

2. Medication adjustments:

   • If headaches persist despite NSAIDs: Add triptan therapy for breakthrough headaches 1
   • If nausea persists despite ondansetron: Consider alternative antiemetics
   • If symptoms continue beyond 4-6 weeks: Increase amitriptyline dose gradually (up to 150 mg/day as tolerated) 1

Important Considerations and Pitfalls

• Medication overuse risk: Limit acute headache medications (NSAIDs ≤15 days/month, triptans ≤10 days/month) to prevent medication overuse headache 1

• Cognitive effects: Be cautious with medications that may worsen cognitive symptoms (antihistamines, some antiemetics, high-dose amitriptyline)

• Sleep impact: Consider timing of amitriptyline administration (evening dosing) to leverage sedating effects for sleep disturbances common in post-concussive syndrome

• Contraindications:

  • Avoid propranolol in patients with asthma, bradycardia, or heart block 1
  • Use caution with TCAs like amitriptyline in patients with cardiovascular disease or seizure history 1

• Treatment duration: Symptoms typically resolve within 3-6 months for most patients, but may persist longer in some cases 3

• Monitoring: Evaluate medication efficacy after 4-6 weeks and adjust as needed 1

Non-Pharmacological Approaches to Complement Medication

• Regular sleep schedule and adequate hydration
• Stress management techniques
• Gradual return to cognitive and physical activities (sub-symptom threshold)
• Consider vestibular therapy if dizziness is prominent
• Vision therapy if visual symptoms are present

Remember that while these medications address acute symptoms, they should be part of a comprehensive approach that includes appropriate rest followed by gradual return to activities as symptoms allow.