Dylan M. Wood, MD
Resident Physician
University of Miami Jackson Health
Miami, Florida, United States
Jose R. Vives, MD
Assistant Professor / Attending Physician
University of Miami Miller School of Medicine / PM&R Department
Miami, Florida, United States
Headaches are a common symptom after a traumatic brain injury (TBI) but can often occur in populations that suffer a concomitant traumatic spinal cord injury (SCI). These headaches can be potentiated by factors that after often seen in SCI such as orthostatic hypotension, autonomic dysreflexia (AD), and post-concussive symptoms.
Case Description:
Patient is a 24-year-old male without PMH that was involved in a scooter vs motor vehicle collision resulting in a small right frontal contusion, small left posterior parietal traumatic subarachnoid hemorrhage, C6-C7 fracture dislocation resulting in a tetraplegic SCI. During the patient’s rehabilitation course, he had moderate daily headaches resistant to conventional medicines of Tylenol and abortive meclizine. Patient was begun on 25mg of nortriptyline with resolution of his daily headaches there afterwards.
Discussions:
Nortriptyline inhibits the reuptake of both serotonin and norepinephrine at the presynaptic membrane. This medication could be vital in the use of treating persistent headaches in patients with dual diagnoses of both TBI and SCI. Multiple medications are used for chronic headaches but are not tolerable to this population for multiple reasons. For example, propranolol is often used in the population; however, due to the bradycardia that can be experienced with an SCI this would cause further slowing of the heart rate and lower blood pressure. Topiramate can be used; however, in patients with TBI this can worsen cognitive slowing and thus lead to a longer recovery process.
Conclusions:
Nortriptyline can be a viable option in the treatment of persistent headaches in a population of people who experience both TBI/SCI. It is important for physiatrists to have this medication in mind for treatment due to the complex changes in the body after such injuries.
