Is diclofenac (Nonsteroidal Anti-Inflammatory Drug (NSAID)) contraindicated in patients with head injuries?

Is Diclofenac Contraindicated in Head Injury?

Diclofenac is not absolutely contraindicated in head injury, but regular long-term use of NSAIDs including diclofenac should be avoided in patients with head trauma due to increased risk of intracranial hemorrhage. 1

Evidence for NSAID Risk in Head Injury

The American Heart Association/American Stroke Association guidelines explicitly state that regular long-term use of NSAIDs is potentially harmful in patients with intracranial hemorrhage because of increased bleeding risk. 1 Specifically:

• Diclofenac carries elevated hemorrhagic stroke risk compared to other NSAIDs, with a large meta-analysis demonstrating increased risk of intracranial hemorrhage with diclofenac and meloxicam use. 1

• A subsequent comprehensive meta-analysis found increased risk of intracranial hemorrhage with any NSAID use, not just diclofenac. 1

Context-Specific Considerations

Acute Pain Management After Head Injury

For acute pain relief in head-injured patients:

• Acetaminophen (paracetamol) should be first-line for pain management in trauma patients, including those with head injuries. 2

• If acetaminophen is contraindicated (e.g., allergy), ketorolac may be considered as an alternative NSAID with careful monitoring, though this represents short-term use rather than chronic administration. 3

• Opioid-sparing strategies are preferable in head injury patients to avoid masking neurological deterioration. 3

Antiplatelet Effects and Bleeding Risk

The trauma literature demonstrates specific concerns:

• Patients on antiplatelet agents (excluding aspirin alone) have significantly elevated risk of intracranial injury after head trauma. 1

• While these studies focused on chronic antiplatelet use rather than acute NSAID administration, the mechanism of platelet inhibition is relevant to bleeding risk. 1

Clinical Decision Algorithm

For patients with head injury requiring analgesia:

1. First-line: Acetaminophen at regular intervals (every 6 hours) for adequate pain control 2

2. If acetaminophen insufficient or contraindicated:

   • Consider short-term opioids for moderate-severe pain 2
   • Ketorolac may be used cautiously for brief duration (<2 weeks) if opioids are contraindicated 3, 2

3. Avoid diclofenac and other NSAIDs for:

   • Regular long-term use in any patient with history of intracranial hemorrhage 1
   • Patients with documented intracranial bleeding on imaging 1
   • Elderly patients with head trauma (higher baseline bleeding risk) 1

Important Caveats

• The evidence specifically addresses chronic/regular NSAID use rather than single-dose or very short-term administration. 1

• No absolute contraindication exists for single-dose diclofenac in minor head injury without intracranial bleeding, though safer alternatives are preferred. 1

• If NSAIDs must be used, co-prescribe proton pump inhibitors to reduce gastrointestinal complications, and monitor renal function closely. 2

• Recombinant factor VIIa use in isolated head injury has been shown to be harmful, increasing mortality risk regardless of injury severity, which underscores the importance of avoiding medications that promote bleeding in this population. 1