Primary care clinicians are now advised to treat patients with traumatic brain injuries who have symptoms such as headache and dizziness right away, rather than waiting to see if they improve on their own, according to the guideline published in the Annals of Family Medicine from a working group at the National Academies of Sciences, Engineering, and Medicine.

The guideline is intended for treatment of adults in the first 6 months following traumatic brain injury (TBI) and covers topics such as assessment, treatment initiation, education, and referrals. The recommendations are for the treatment only of patients who required brief hospitalization and can manage on their own after discharge or were not hospitalized.

In the weeks and months after patients leave the emergency department following a TBI, they “often get lost in the healthcare system” and do not receive follow-up care from their primary care clinician, said Noah Silverberg, PhD, co-chair of the group that wrote the guideline and associate professor at the University of British Columbia in Vancouver, British Columbia, Canada.

At least 50 million people worldwide sustain a TBI each year. In the US in 2020, approximately 214,110 people were hospitalized for health issues associated with such injuries. While most patients fully recover, many experience persisting symptoms, reduced quality of life, and disability. Fewer than half of patients with a TBI see a physician after leaving the emergency department, and those who do receive various treatments depending on the physician rather than on a standardized set of guidelines.

The authors of the new guideline synthesized and revised recommendations from 18 existing guidelines written by various organizations in several countries, including the US, the UK, and France.

Silverberg said many guidelines focus on subpopulations, including athletes or military service members, leaving a large gap in recommendations for TBI from any cause, such as falls, motor vehicle crashes, and assaults.

“We see the guideline as a way of making concrete what doctors should be paying attention to,” Silverberg said.

Screening for High-Risk Patients

Clinicians should screen patients to identify those at high risk for persistent symptoms, such as poor sleep and cognitive problems. The guideline advises clinicians to consider referring patients who continue to experience disabling symptoms 1 month after injury to neurologists, physical therapists, or rehabilitation medicine specialists. Patients who have ongoing headaches can receive first-line drugs such as acetaminophen, ibuprofen, or naproxen, or triptans for migraine.

For about one third of patients, concussions and mild TBIs do not resolve, said John Leddy, MD, medical director of the Concussion Management and Research Center at the University at Buffalo in Buffalo, New York, and the author of an editorial accompanying the journal article. Primary care clinicians “can do something actively to help these brain injury patients recover,” rather than waiting for months to see if symptoms persist, he said.

The guideline also directs primary care physicians to screen for new-onset or worsening mental health conditions.

“We know that the risk of depression and anxiety disorders are hugely elevated in the months following injury and make a massive difference to outcome, tripling the risk of long-term disability,” Silverberg said.

Leddy said a recommendation that stood out to him advises clinicians to prioritize treating symptoms that are most bothersome to the patient and impede rehabilitation. Clinicians should also advise patients to rest for 2 days after injury and to gradually resume daily activities.

The guideline singles out older adults, survivors of intimate partner violence, and military service members for special consideration. For example, clinicians should focus on fall prevention in assessing older adults’ resumption of activity and safety in the home.

Survivors of intimate partner violence “frequently have a history of multiple TBIs, which may have gone unaddressed. Those patients may present with a known TBI or with symptoms that, upon further investigation, reveal a TBI and/or strangulation-induced hypoxic event,” the guidelines state. “Co-occurring mental health conditions such as posttraumatic stress disorder are common and can complicate retrospective diagnosis.”

Silverberg and colleagues developed a knowledge translation plan to accelerate implementation of the guideline, including development of a network of TBI clinics to serve as demonstration sites employing the steps. Their team will eventually evaluate the effectiveness and progression of guidelines, including referrals from primary care clinicians.

One recommendation not available in other guidelines is for screening all patients for social determinants of health, including access to food, housing and transportation, and immigration status. Clinicians should consider these factors in planning individualized care because they significantly affect a patient’s ability to obtain and adhere to treatment, the guideline states.

“There’s no point in recommending therapy if you know the patient can’t get time off of work or can’t pay for it or can’t get themselves there,” Silverberg said.

Silverberg reported receiving grants from the Canadian Institutes of Health Research, Canada Foundation for Innovation, Mitacs, Ontario Brain Institute, the US Department of Defense, WorkSafeBC, and VGH & UBC Hospital Foundation. Leddy reported serving as a consultant for NeckCare and ZEISS and holding a minority ownership position in 360 Concussion Care.

Brenda Sandburg is a freelance journalist based in New York City. She has written about the biopharmaceutical industry and legal issues for The Pink Sheet and American Lawyer Media.