What is the best treatment approach for a 33-year-old female patient with a history of untreated Attention Deficit Hyperactivity Disorder (ADHD) who suffered a concussion 7 months ago, currently experiencing headaches, neck and shoulder pain, executive dysfunction, memory issues, difficulty with concentration and focus, emotional reactivity, and bladder control problems, and is currently being treated with Qelbree (viloxazine), Wellbutrin XL (bupropion), and Prozac (fluoxetine), and has undergone vestibular physical therapy and trigger point injections?

Management of Persistent Post-Concussion Syndrome with Pre-existing ADHD

This patient requires immediate implementation of interdisciplinary coordinated rehabilitation combining graded physical exercise, vestibular rehabilitation continuation, psychological treatment, and cervical spine manual therapy, while maintaining current ADHD pharmacotherapy with close monitoring for suicidal ideation given Qelbree's black box warning. 1, 2, 3

Critical Safety Consideration

• Monitor closely for suicidal thoughts and behaviors given Qelbree carries a black box warning showing 0.9% of pediatric patients and 1.6% of adult patients developed suicidal ideation versus 0.4% and 0% respectively on placebo 3
• The combination of emotional reactivity, concentration difficulties, and irritability may represent precursors to emerging suicidal ideation, requiring immediate assessment at each visit 3
• Screen specifically for insomnia worsening and increased irritability as these symptoms correlate with higher suicidal risk in Qelbree-treated patients 3

Immediate Treatment Priorities

1. Interdisciplinary Coordinated Rehabilitation (Primary Recommendation)

Implement treatment from at least two healthcare disciplines (physical therapy, psychology, occupational therapy) meeting at least weekly for minimum 4 weeks, as this approach demonstrates the strongest evidence for persistent symptoms at 7 months post-injury 1, 2

• This intervention shows positive effects on overall symptom burden, physical functioning, emotional symptoms, quality of life, and return to work outcomes 1, 2
• The evidence quality is low but represents the most comprehensive approach for multi-domain symptoms persisting beyond 3 months 1

2. Graded Physical Exercise Program

Initiate sub-symptom threshold aerobic exercise with gradual intensity increases, performed minimally once weekly for 4 weeks 1, 2, 4

• This intervention demonstrates positive effects on headaches, executive dysfunction, emotional symptoms, and overall symptom burden 1
• Exercise should remain below the threshold that exacerbates symptoms, then gradually increase in complexity and intensity 2
• Given 7-month duration, this patient is well past the acute 24-48 hour rest period and requires active rehabilitation 5

3. Psychological Treatment for Emotional Reactivity and Executive Dysfunction

Refer for individual cognitive behavioral therapy at least 1 hour weekly for minimum 4 weeks to address emotional reactivity, concentration difficulties, and memory issues 1, 2

• Psychological treatment shows positive effects on emotional symptoms, overall symptom burden, and quality of life at longest follow-up 1
• The combination of pre-existing untreated ADHD and post-concussion cognitive symptoms creates compounded executive dysfunction requiring specialized intervention 1
• CBT specifically targets the anxiety and emotional dysregulation common in persistent post-concussion syndrome 2

4. Cervical Spine Manual Therapy

Continue and potentially intensify manual therapy (mobilization/manipulation) for persistent neck and shoulder pain 1, 2, 4

• Manual therapy demonstrates positive effects on pain reduction and physical functioning 1
• Cervicogenic contributions to headache are common after backward falls with head impact 4
• Treatment should be provided by physiotherapists or chiropractors minimally once weekly 1

5. Oculomotor Vision Assessment and Treatment

Obtain formal oculomotor evaluation for vergence, accommodative, and eye movement dysfunction given concentration difficulties and processing issues 1, 2, 4

• While no controlled trials exist, clinical consensus strongly supports oculomotor therapy for visual symptoms, headache reduction, and improved concentration 1, 2
• Computer-based training and optometric instrumental training should be administered minimally once weekly for 4 weeks if dysfunction identified 1
• Visual dysfunction commonly contributes to difficulty processing complex information and concentration problems 2

Pharmacotherapy Management

Current ADHD Medication Regimen

Continue current regimen of Qelbree 100mg, Wellbutrin XL 150mg, and Prozac 40mg but consider dose optimization 3

• The current Qelbree dose (100mg) is at the minimum starting dose for adults; FDA labeling recommends titrating to 200-600mg daily in 200mg weekly increments based on response 3
• Consider increasing Qelbree to 200mg daily after assessing current tolerability and response, as most adult patients require higher doses for optimal ADHD symptom control 3, 6
• The combination of norepinephrine reuptake inhibition (Qelbree, Wellbutrin) with serotonergic activity (Prozac) addresses both ADHD and emotional symptoms 7, 8

Monitoring Requirements

• Assess heart rate and blood pressure before any Qelbree dose increases and periodically during treatment, as 29% of adults experience ≥20 bpm heart rate increases and 13% experience ≥15 mmHg diastolic blood pressure increases 3
• Monitor for activation of mania or hypomania given noradrenergic mechanism 3
• Screen for emergence of insomnia or worsening irritability at each visit 3

Bladder Dysfunction Management

Refer to urology or urogynecology for persistent bladder control issues at 7 months post-injury 9

• While bladder dysfunction can occur acutely after concussion, persistence at 7 months suggests need for specialized evaluation beyond standard post-concussion management 9
• Rule out neurogenic bladder versus behavioral/functional causes 9

Headache-Specific Management

Assess for medication overuse headache given 7-month duration and ongoing pain management 4

• Chronic headache after concussion is multifactorial and analgesic overuse may be contributory 4
• If using NSAIDs or acetaminophen more than 10-15 days monthly, implement withdrawal protocol 4
• The combination of manual therapy, graded exercise, and psychological treatment addresses headache through multiple mechanisms 4

Return to Work Optimization

Implement graduated return-to-work accommodations including reduced hours, modified duties, and scheduled breaks 2, 5

• The patient's current struggle with work functions after 5 months back requires formal workplace accommodations 5
• Coordinate with occupational therapy for specific cognitive strategies and workplace modifications 2
• Monitor symptom exacerbation with work activities and adjust accordingly 5

Common Pitfalls to Avoid

• Do not assume all cognitive symptoms are post-concussion related - this patient has untreated ADHD history that compounds executive dysfunction 1
• Do not continue passive treatments indefinitely - at 7 months, active rehabilitation with graded exercise is essential 1, 2
• Do not overlook the 15-20% of patients who develop persistent symptoms requiring intensive intervention - this patient clearly falls in this category 2, 5
• Do not ignore the multifactorial nature of symptoms - cervical, vestibular, visual, psychological, and ADHD components all require simultaneous attention 9, 10

Prognosis and Follow-up

• Schedule reassessment in 4 weeks to evaluate response to intensified interdisciplinary treatment 1, 2
• Female gender, high early symptom burden, and 7-month duration are risk factors for prolonged recovery requiring sustained intervention 5, 9
• If no improvement after 4 weeks of coordinated treatment, consider referral to specialized traumatic brain injury clinic 5