3.3.2 Recommended Pharmacological Measures

When non-pharmacological measures are unsuccessful which medications are recommended to decrease aggressive and agitated behaviours?


Atypical antipsychotics prn – Risperidone up to 3 gm daily; alternative Seroquel or Olanzepine


If ABS > 28 then provide scheduled dose medications        

1.    Beta-blockers

2.    Anticonvulsants (i.e Valproic Acid)

3.    SSRI (Sertraline)

4.    Tricyclic antidepressants (Amtriptyline titrated up to 75 mg/day)

5.    Methylphenidate

6.    Avoid the use of antipsychotic drugs such as Haldol.

  • Multiple neuropharmacologic agents early in the treatment of posttraumatic brain injury agitation may be an effective therapeutic intervention for both behavioral and cognitive problems.  
  • The best evidence of effectiveness in the management of agitation and/or aggression following ABI was for beta-blockers20.
  • Anticonvulsants and beta-blockers are the two classes of drugs most often recommended.
  • More research is needed to assess the role of other medications and medication combinations such as Amantidine, Ritalin, Trazadone and Dexedrine 21.
  • Clinically, atypical anti-psychotic medications are frequently used early on because they act so quickly even though there is not much in the way of research evidence; later the other medications which have been better studied are utilized.

According to ABIKUS Guidelines (2007)

Recommended Pharmacological Measures

  1. “Thereshould be careful considerations of the sensitivity of people with traumatic brain injury to psychotropic medication before trial use. Psychotropic medications should be used with caution. Where medications are clinically indicated ‘start low and go slow’, keep under direct clinical monitoring to ensure that the drug is tolerated and producing the expected improvement and used with caution where indicated. (pg 18)
  2. Perform a detailed physical exam prior to commencing any trial of medications. People with traumatic brain injury and their caregiver should be asked about any prescribed medications, over the counter remedies, herbs or supplements they are taking to check for potential interactions and adverse effects. (pg 18)
  3. Appropriateinvestigations should be completed prior to medication trials to rule out and minimize metabolic abnormalities including evaluation of: plasma blood sugar, electrolytes, hormones, hemoglobin, oxygenation and infection. (pg 18)
  4. Clinicians should also consider the possibility of brain injury related sleep disorders as a cause of cognitive and other behavioural changes. (pg 18)
  5. Any trial of medication for a person with traumatic brain injury should be preceded by a clear explanation to the person with traumatic brain injury and their caregivers, and a caution that effects of medications are less predictable in people with traumatic brain injury. (pg 18)
  6. Minimize use of Benzodiazepines and Neuroleptic antipsychotic medicationsas animal studies suggest these medications may slow recovery after brain injury. (pg 18)
  7. Beta Blockersare recommended; a guideline for the treatment of aggression after TBI. Studies reported the efficacy of both Propranolol (maximum dose 420-520 mg/day) and Pindolol (maximum dose 40-100 mg/day) in the treatment of aggression in this population. (pg 19)
  8. Anticonvulsants:Carbamazepine and/or Valproic Acid may be used to decrease the incidence of aggressive behaviours. (pg 19) 
  9. Valproic Acid may be preferred over Phenytoin post brain injury as it does not have any significant neuropsychological side effects, and is effective for controlling established seizures and stabilizing mood. (pg 19)”