Introduction.

A concussion is a type of traumatic brain injury (TBI) caused by a blow to the head and/or body, leading to a range of physical, cognitive, and emotional symptoms. Common symptoms include headaches, dizziness, confusion, difficulty concentrating, and sensitivity to light or noise. 

Understanding the effects of sleep after a concussion is crucial, as sleep is a critical component in the recovery process. However, in the past, it was a common belief that you should not let someone with a concussion fall asleep immediately following a head injury. 

In this article, we will explore…

  • The importance of sleep after a concussion
  • Identify common sleep-related issues that may arise
  • Address whether it’s safe to let someone sleep following a head injury
  • Provide practical recommendations for promoting healthy sleep during recovery

The Importance of Sleep.

Sleep plays a vital role in the recovery process following a concussion and has restorative functions on the brain. Sleep deprivation can significantly exacerbate concussion symptoms, such as headaches, irritability, and difficulty with concentration. Insufficient sleep may also impair cognitive function and slow recovery, leading to a cycle where symptoms contribute to disturbed sleep patterns, and poor sleep leads to symptoms.

Research has consistently highlighted the critical role sleep plays in the healing process post-concussion, including:

  • Restorative Functions: Sleep promotes brain recovery and healing through neuroplasticity and reduced inflammation (Donahue et al., 2024).
  • Symptom Management: Adequate sleep can reduce common concussion symptoms and promote a faster recovery (Hoffman et al., 2020).
  • Cognitive Recovery: Healthy sleep supports faster cognitive function recovery and prevents long-term impairments (Kostyun et al., 2015).
  • Mood and Stress Regulation: Proper sleep can manage stress and enhance mood, facilitating the recovery process (Maerlender et al., 2020).
  • Neural Recovery: Improved sleep quality positively influences neurological outcomes and brain structure (Lima Santos et al., 2022).
  • Recovery Duration: Sufficient sleep is linked to quicker recovery times and better rehabilitation results (DuPrey et al., 2022).
  • Prevention of Prolonged Symptoms: Addressing sleep disturbances early in recovery minimizes the risk of persistent concussion symptoms (Hoffman et al., 2020).

In conclusion, prioritizing sleep during concussion recovery is essential for symptom management, cognitive and neural recovery, and reduced recovery time, while minimizing the risk of prolonged symptoms.

Common Sleep Problems after a Concussion.

Sleep problems are common following a concussion, affecting roughly 70% of individuals as they recover from the injury (Gosselin et al., 2009). Sumpter et al. (2013) investigated the prevalence and nature of sleep difficulties in pediatric patients following moderate to severe traumatic brain injuries (TBIs). They found that sleep disturbances were common in this population, manifesting as insomnia (“inability to sleep”), hypersomnia (“too much sleep”), and other sleep disorders.

Along the same lines, Rao et al. (2008) examined the prevalence and various types of sleep disturbances experienced shortly after a traumatic brain injury (TBI). They found that sleep disorders, such as insomnia, hypersomnia, and obstructive sleep apnea, were common among TBI patients in the acute phase of recovery. They highlighted that these disturbances significantly affect overall rehabilitation outcomes, increasing fatigue and impairing cognitive function.

Common sleep problems following a concussion include:

InsomniaDifficulty falling or staying asleep. 
HypersomniaExcessive sleepiness during the day leads to prolonged napping and disrupted nighttime sleep.
Nightmares & Sleep DisturbancesVivid dreams or nightmares that accompany restless sleep.
Sleep ApneaBreathing irregularities during sleep.
Difficulty WakingIncreased drowsiness and challenges in waking up.
Restless Leg Syndrome (RLS)Uncomfortable sensations in their legs lead to an urge to move, hindering peaceful sleep.
Decreased Sleep QualityA noticeable decline in sleep’s therapeutic nature results in increased fatigue and other symptoms.

Recognizing and addressing these common sleep problems is essential for promoting effective recovery and overall well-being following a concussion.

Can You Sleep Immediately After a Concussion?

In past concussion management practices, the prevailing advice was to frequently awaken someone who had suffered a concussion every hour or two during the night. This precaution was not due to the concussion itself, but founded on the concern that if a person had something more serious, such as an undetected brain bleed, they might slip into unconsciousness while sleeping, potentially delaying crucial medical intervention. 

Regularly waking the person aimed to ensure they could be easily roused and were not exhibiting any worsening symptoms. If difficulties arose in arousing them, or if they began to display slurred speech or other signs of neurological decline, it was thought better to address these issues earlier rather than discover them the following morning, when the opportunity for timely intervention might have already passed.

Current recommendations have shifted from the previous practice of frequently waking a person during the night, to keeping them awake for only 2-4 hours after the injury, when these serious issues typically become apparent. If the patient has had no red flags during this 2-4 hour period, then rest is advocated and they are allowed to sleep through the night.

All in all, if concerns persist, it is acceptable to wake the individual throughout the night, as this practice does not negatively affect concussion recovery. It remains a safe option to ensure their well-being. However, most individuals can safely sleep through the night if no warning signs appear during the initial 4-hour period following the injury.

Red Flags to Look Out for.

Prior to letting someone sleep, we are most concerned with things like bleeding in the brain, swelling of the brain, skull fractures, and neck fractures. While a concussion itself may not be fatal, these other injuries can be. Therefore, during this critical time 2-4 hours post head injury, it’s essential to keep the individual awake and closely monitor for red flags. 

Red flags are signs and concussion symptoms that may point to a more serious head injury, and one that could be potentially fatal. When any red flags are present or you are in any way unsure, a patient should be immediately sent to the Emergency Department for further assessment. It is at this point they will also be assessed on the need for further imaging such as an MRI or CT scan, used to investigate for more serious structural injuries such as fractures, bleeding in the brain and swelling.

At Complete Concussions, we follow the guidelines called the New Orleans Criteria and the Canadian CT Head Rule, to ensure that no potential issues are overlooked. We believe that any indication of a red flag warrants immediate medical evaluation at the emergency room to rule out serious complications.

Red flags you should be looking for include:

  • Severe or Worsening Headache
  • Vomiting – The New Orleans criteria states vomiting once is a warranted trip to emergency, whereas the Canadian CT Head rule says two or more episodes. We lean toward the New Orleans criteria.
  • Age – New Orleans criteria says anyone who is 60 years of age or older should get a CT scan, while the Canadian CT Head rule says 65+. Again, we tend to be more cautious and say if you are 60 or older, you should get checked out in the ER.
  • Drugs – if there was drug or alcohol intoxication reported at the time of injury, a scan should be completed.
  • Anterograde amnesia – Having persistent anterograde amnesia, which is the inability to form new memories after the accident (ie. the player or patient keeps asking ‘why am I here?’).
  • Retrograde amnesia – Amnesia of 30 or more minutes before the impact (Canadian CT head rules). For us at Complete Concussions, we would consider any amnesia 30 minutes before or after the injury to be a red flag.
  • Visible trauma above the clavicle
  • Signs of skull fracture – an open / visible fracture; palpable discrepancy in the bony contour; bloody ear discharge; cerebrospinal fluid draining from the ears or nose; bruising behind the ears (battle sign); bruising around the eyes (racoon eyes); facial paralysis; nystagmus (flickering of the eyes); paresthesia (numbness or tingling); abnormal pupillary reflex (when you shine a light in someone’s eye, their pupil should constrict. After a concussion, sometimes you will see pupils that stay dilated, or one pupil is larger than the other); vomiting and altered mental state. These are all signs of a possible skull fracture.
  • A dangerous mechanism – Defined as being struck by a vehicle or ejected from a vehicle; a fall from an elevation of three or more feet or five or more stairs.

By staying alert for these warning signs, caregivers can ensure that individuals recovering from a concussion receive emergent medical care, if needed.

Read more about signs and symptoms and red flags in our older post here.

If none of these red flags appear within the initial period, it is generally safe to allow the person to sleep without additional monitoring.

Sleep Hygiene Recommendations.

Sleep plays a crucial role in the recovery process following a concussion. Quality sleep supports brain healing, helps manage symptoms such as headaches and irritability, and can improve overall cognitive function. Ensuring adequate rest in the early stages of recovery can make a significant difference in the speed and efficacy of the healing process.

Here are some ways to promote better sleep:

  1. Optimize the Sleep Environment: Ensure the sleep space is quiet, dark, and cool. Heavy curtains or blackout shades can block out excess light, and earplugs or white noise machines can mitigate disruptive sounds. The ideal room temperature is typically between 15-19°C (60-67°F).
  2. Establish a Regular Sleep Schedule: Encourage going to bed and waking up at the same time each day to help regulate the body’s internal clock. Consistency reinforces better sleep quality and helps manage fatigue levels.
  3. Limit Screen Time Before Bed: The blue light emitted by phones, tablets, and computers can interfere with melatonin production, making it harder to fall asleep. It is advisable to limit/stop screen usage at least 30-120 minutes before bedtime.
  4. Promote Relaxation Techniques: Incorporating calming pre-sleep activities such as reading (physical book, not lit screen), gentle stretching, journaling, or meditation can help ease the mind and body, promoting a smoother transition to sleep. Deep breathing exercises may also reduce anxiety or restlessness.
  5. Avoid Stimulants and Heavy Meals: Reducing or eliminating caffeine intake, particularly 10-12 hours before bedtime, is crucial. Additionally, heavy meals should be avoided close to bedtime (e.g., provide 3-4 hours before bed) to prevent discomfort that could disrupt sleep.
  6. Encourage Short Naps if Needed: While longer naps can disrupt nighttime sleep, brief naps (15-30 minutes) can provide a helpful boost in alertness during the day as long as they do not interfere with the primary sleep schedule.

By following these guidelines, individuals recovering from a concussion can enhance their sleep quality, promote healing, and support overall recovery processes.

Conclusion.

In conclusion, sleep is a foundational component of the recovery process following a concussion. Adequate and quality sleep plays a vital role in supporting brain healing, managing post-concussion symptoms, and enhancing overall cognitive function, which are all crucial for a successful recovery. By creating a conducive sleep environment, maintaining a consistent sleep schedule, and incorporating relaxation techniques, individuals can significantly improve their sleep quality and, thus, their healing process. Prioritizing sleep in the aftermath of a concussion can make a profound difference in how quickly and effectively a person returns to their normal activities and cognitive health.

References
  1. Donahue, C. C., & Resch, J. E. (2024). Concussion and the sleeping brain. Sports Medicine – Open, 10(68). https://doi.org/10.1186/s40798-024-00736-2.
  2. DuPrey, K. M., Char, A. S., Loose, S. R., Suffredini, M. V., Walpole, K., & Cronholm, P. F. (2022). Effect of sleep-related symptoms on recovery from a sport-related concussion. Orthopaedic Journal of Sports Medicine. Jul 15;10(7).
  3. Gosselin N, Lassonde M, Petit D, et al. Sleep following sport-related concussions. Sleep Med. 2009;10(1):35–46. doi: 10.1016/j.sleep.2007.11.023.
  4. Hoffman, N. L., O’Connor, P. J., Schmidt, M. D., Lynall, R. C., & Schmidt, J. D. (2020). Relationships between post-concussion sleep and symptom recovery: A preliminary study. Journal of Neurotrauma, 37(8), 1029-1036. https://doi.org/10.1089/neu.2019.6761.
  5. Hoffman, N. L., Weber, M. L., Broglio, S. P., et al. (2020). Influence of postconcussion sleep duration on concussion recovery in collegiate athletes. Clin J Sport Med, 30 Suppl 1, S29–35. 
  6. Jaffee, M. S., Winter, W. C., Jones, C. C., & Ling, G. (2015). Sleep disturbance in athletic concussion. Brain Inj., 29, 221–227. 
  7. Kostyun, R. O., Milewski, M. D., & Hafeez, I. (2015). Sleep disturbance and neurocognitive function during the recovery from a sport-related concussion in adolescents. The American Journal of Sports Medicine, 43(3), 633-640. https://doi.org/10.1177/0363546514560727.