Pain Management After Traumatic Brain Injury (Part 2)

Main with Headache

Treating pain for people with TBI can be tricky. Pain should be treated aggressively and sufficiently, but not to the point that the recovering brain becomes groggy and confused. Aggressive pain management immediately following a TBI will have a positive effect on overall patient recovery, while a distracted brain (i.e., one consumed by pain) is one that does not recover well.

Your doctor will walk a fine line treating pain after a TBI – no one approach will fit all patients, and your doctor will have to take into consideration each person’s perspective, the nature of the injury, and the recovery plan. The aggressiveness of the treatment should aim to be both effective and preserve brain function. It is important to keep in mind that the brain is more sensitive after a TBI, possibly due to disruptions in the blood-brain barrier, and to other medications (and their side effects) after TBI. “Start low and go slow” should be the mantra when starting a pain medication.

At the doctor’s appointment, the first consideration will be to determine what is causing the pain. Is it from physical injury, headache, depression, or lack of sleep? Your doctor will have you describe the pain in great detail by walking through specific details—location, severity, quality, intensity, aggravating/alleviating factors, onset, and timing. Your doctor might then use other assessments to better understand the context of the pain. You might be asked questions about depression, anxiety, post-traumatic stress, or insomnia.

Second, your doctor will determine how invasive the pain is to your life. Does it interfere with everyday functioning? Does it affect your mood? Is it physically limiting? Is it causing you to isolate yourself or feel depressed? The doctor will assess if the pain is a primary problem, or if it exists as a result of another issue. The doctor could consider if your pain affects attention and concentration—which may contribute to lower scores on neuropsychological assessments. The doctor may even try to re-create a situation where you feel pain, to better assess it.

Third, your doctor will assess what others perceive about your pain. Your doctor may discuss this with other healthcare professionals and caregivers involved in your care. This will help the doctor understanding things that you might not notice. For example, your spouse may be able to provide detailed information about breakthrough pain that you might not realize or remember.

Fourth, your doctor will assess what symptoms are already being treated or need to be treated in addition to the pain. The reason for teasing apart pain from other TBI-related issues is that these symptoms can overlap or compound to make the perception of pain better or worse. For example, if you have sleep apnea and depression, the lack of oxygen and disrupted sleep from the sleep apnea can make the depression worse. And both having both sleep apnea and depression can reduce your threshold for pain. Treating the sleep apnea may reduce the depression – so that, ultimately, your tolerance for pain will also become better.

When treating headache pain after TBI, your doctor will consider the type of headache and any factors that might contribute to it (time of day, sensitivity to light, etc.). If your headache severity can be decreased by the wearing of sunglasses, or by having regularly scheduled acupuncture sessions for myofascial pain management, then these options may be preferred over prescribing headache medications which may cause drowsiness, medication over-use headaches, and fatigue.

Pain caused by co-morbid orthopedic injuries can delay TBI recovery. A person who is preoccupied with pain will not fully participate in rehabilitation, and therefore will not recover as well or as quickly. Your doctor should try to use the lowest possible dose of narcotic pain medications for the shortest period of time so as to preserve cognitive function and recovery. Other treatment techniques should be considered in addition to pain medication. For example, someone recovering from orthopedic surgery might benefit acupuncture, meditation, biofeedback, cognitive-behavioral training and recreation therapy in addition to standard pain management techniques (physical therapy, ice/heat, medication).

Medications that target more than one issue can also be beneficial. For instance, serotonin-reuptake inhibitors (like Cymbalta) can treat both depression and pain, muscle relaxants and drugs (like Gabapentin) can treat common TBI-related issues such as anxiety or seizures as well as pain. There can be effective ways to manage pain without focusing on the use of narcotics or other pain medicines.

Finally, your doctor should schedule frequent re-assessment of your pain to better manage it and adjust the treatment plan as needed. This can be accomplished through frequent follow-up until you experience a stabilization of the pain.

There are some medications that, in general, should be avoided after a TBI. These include include benzodiazepines, doxylamine (and other anticholinergics like Clonidine), Haloperidol, Chlorpromazine and Thioridazine, and medications with strong NMDA-receptor activity (such as Fentanyl and Tramadol). Your doctor will consider this, and prescribe a medication that offers both effective pain relief that is targeted to the type of pain you are experiencing, as well as the lowest number of negative side effects.

Pain is a common complaint among people with a TBI, and it has a major role in the recovery process and treatment success. There are many factors that influence the development of pain after TBI, including the demographics, mechanism of injury, concurrent disorders or injuries, and severity of the injury. Treatment of pain must use an interdisciplinary, multi-modal approach in order to be effective and support positive outcomes. Successful pain management requires doctors be thorough in their assessment, familiar with pain treatment medications and modalities, and open to using non-pharmacologic treatment options. Sufficient pain management improves quality of life, return to work and social reintegration, and should not be overlooked when creating the recovery plan.

This table illustrates some examples of acceptable medication class options.

Pain source





Medication classes to consider


Neuromodulating drugs (Gabapentin, Pregabalin, Carbamazepine, Oxcarbamazepine)

SSRI’s (Sertraline, etc.)

Prophylactic meds (Topiramate, Propranolol, Setraline etc.)


SNRI’s (Duloxetine)

SNRI’s (Duloxetine)

Abortive meds (Triptans*, NSAID’s*)

Muscle relaxants**

Muscle relaxants** (for treatment of contractures)

Adjunctive medications: muscle relaxants (for cervicogenic headaches), anti-nausea medications (Promethazine)

Narcotic pain medications*

TCA’s (Nortriptyline)

TCA’s (Nortriptyline)

Neuromodulating drugs (effective in myofascial pain, such as Gabapentin or Pregabalin)

Mood-altering medications with mixed mechanism of action (Venlafaxine)

Mood stabilizing medications (SSRI’s, SNRI’s)

*If possible, limit use to 2 to 3 days per week to prevent medication-overuse headaches

**Use the lowest-dose possible for shortest period of time necessary keeping in mind that the effects are greater in TBI patients; Avoid centrally-acting muscle relaxants if possible

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