The consumption of alcohol has been the topic of many headlines in recent years, as there are ever-changing opinions on…
In this blog, we are going to dive into all things “alcohol and brain recovery” related and explain why avoiding alcohol during concussion healing gives you the best chance for a quick and complete recovery.
While there are many different forms of alcohol, they all have varying concentrations of a substance called ethanol, which is the psychoactive and toxic substance that provides the “buzz” associated with the consumption of alcoholic beverages. As we break ethanol down, we create another molecule called acetaldehyde, which is the primary driver of negative symptoms like nausea, headache, flushing, and hangover symptoms. Acetaldehyde is even categorized as a Group 1 carcinogen, increasing the risk for certain cancers. While there is some evidence that the consumption of alcohol can lead to some positive social benefits, it is abundantly clear that physiologically, ethanol and its breakdown product, acetaldehyde, are toxic to many different bodily systems.
In the general population, there are guidelines on what is considered a “safe” or “low-risk” amount of alcohol consumption:
https://www.ccsa.ca/canadas-guidance-alcohol-and-health.
Generally, less is better, and the only “safe or healthy” amount of alcohol to drink is zero.
When you are recovering from a traumatic brain injury, abstaining from any alcohol is even more critical because of the increased risks associated with worsening your condition.
You need to abstain from drinking alcohol until your concussion has fully recovered because the risks associated with alcohol consumption are potentially magnified when you have a brain injury.
There are 6 main reasons why alcohol should be avoided entirely until you have been fully cleared by a medical professional:
Let’s break down each of these consequences below.
The “buzz” associated with the consumption of alcohol is primarily mediated by ethanol’s effects on the central nervous system. While this is the reason that many people choose to use alcohol recreationally, it is also one of the biggest reasons why it needs to be avoided after a concussion.
Concussions are characterized by functional changes in the brain’s neurons after an impact on the head or body that causes an acceleration-deceleration event inside the brain (for a full breakdown of the pathophysiology of a concussion, please see our other blog post here).
After the injury, the brain is in a state of energy depletion, which leads to many of the symptoms that we associate with a concussion. During the 30(ish) days after a concussion, the brain will gradually regain its energy levels and return to full function.
What is one of the most significant factors that can impair or prolong this process? Excess inflammation.
Research is being published about the various sources of inflammation and their effects on concussion recovery, namely through the gut-brain axis. However, alcohol is another contributing source of neuroinflammation that can potentially have very adverse effects on your brain’s ability to recover.
Models in both mice and humans have shown that prolonged exposure to alcohol causes inflammation within the brain and can lead to degeneration of the neurons and other brain structures (Lowe et al., 2020). This is hypothesized to be caused by the byproduct of ethanol’s metabolism- acetaldehyde. Acetaldehyde is toxic to the body and can cause inflammation and DNA damage in many different organ systems, including the brain.
Since the brain is already in a vulnerable state after a TBI, we do not want to add any other sources of stress or inflammation during that healing period that may prolong or worsen recovery and symptoms.
Furthermore, alcohol can impair wound healing via its adverse effects on kidney and liver function. This can have harmful effects on brain recovery in patients who sustained physical trauma along with their traumatic brain injury, such as a brain bleed or fracture (Baguley et al., 1997).
In the first 30 days after sustaining an acute concussion, one of the most critical factors associated with recovery is preventing another traumatic brain injury from occurring during the healing period. Head injuries in the short term are additive – and sustaining a second head injury while the first has not entirely resolved puts you at risk of sustaining second impact syndrome, a rare, severe, and potentially life-threatening condition.
It has been well established that alcohol consumption and TBI have a close relationship, with an estimated 30-50% of all concussions occurring during a period of intoxication (Weil et al., 2018). Therefore, if you already have a TBI, alcohol puts you at a significantly increased risk of sustaining a second injury. Ethanol impairs the brain’s ability to carry out motor tasks, reducing coordination, balance, and decision-making. These can lead to an increased risk of falls or other hazardous behaviors that increase the risk of a second concussion and second impact syndrome.
This is further compounded by the fact that people who have sustained a TBI generally have a much lower tolerance to alcohol because TBI and alcohol can have additive effects of impairing brain function. This increases the risk of balance issues, impaired motor vehicle operation, and poor decision-making (Pagulayan et al., 2015).
As mentioned above, alcohol and traumatic brain injuries can have adverse and additive effects on brain function. Hence, adding alcohol to a brain that is already struggling with cognitive tasks has the potential to worsen symptoms severely.
The energy deficit seen after mild traumatic brain injury can contribute significantly to the symptoms experienced in the days to weeks after sustaining a head injury, where the brain has reduced functional capacity compared to pre-injury.
This is one reason why many concussion patients have worsening symptoms when the demand on their brain increases – their brain is struggling to give enough energy to every area that is working. For patients, this commonly presents as increased symptoms in environments with high levels of stimulation, such as on public transit, in a busy restaurant, at school or work, etc.
Alcohol can further worsen this problem because ethanol acts as a depressant on your brain and further impairs cognitive function. This may worsen symptoms associated with your brain’s already low energy levels, such as headache, dizziness, fogginess, feeling “slowed down,” trouble concentrating, etc. It can also affect cognitive performance in areas such as memory and learning, executive functioning, visuospatial skills, processing speed, and gait and balance (Bondi et al., 1998).
Additionally, adding brain-altering chemicals into concussion recovery can make it harder for patients to be able to accurately gauge if they are pushing themselves too hard, not pushing hard enough, or accurately detailing their current level of symptoms during an activity.
Alcohol is a double-edged sword when it comes to sleep and sleep quality. Because of its effect as a depressant (think opposite of caffeine, a stimulant), people think that because alcohol makes them feel more tired, it can be used as a sleep aid. Unfortunately, it is quite the opposite.
While it is true that alcohol initially works as a sedative when you are going to sleep and can help you fall asleep faster, there is a significant reduction in the quality of the sleep you will experience through the night. You will wake feeling unrested and tired, which can increase fatigue levels the next day (Colrain et al., 2014).
Sleep occurs in 4 stages: 3 non-rapid eye movement sleep stages (N1, N2, and N3) and rapid eye movement sleep (REM). Alcohol explicitly affects the amount of REM sleep that you get, with a more prolonged onset of REM sleep and decreased total REM sleep throughout the night. REM sleep is vital because this is when memories are consolidated, emotional experiences are processed, and other brain development occurs.
Those who have suffered a concussion can get into a very negative downward spiral, as concussion alone reduces REM sleep (Mantua et al., 2017). They wake feeling more tired, they self-medicate with alcohol, furthering the reduction in REM sleep, and can end up feeling incredibly exhausted during the day, having trouble regulating emotions, memory recall, etc.
If you are struggling with sleep, here is a link to our blog on sleep post-concussion, which includes the recommended approach to treating sleep difficulties post-concussion (If you couldn’t have guessed already, it does not include alcohol).
After sustaining a head injury, there is a small but significant risk of developing post-traumatic epilepsy (PTE), depending on the severity of the head injury. Post-traumatic seizures are more common in children than adults, but it is estimated that between 5-7% of hospitalized TBI patients will suffer from PTE (Ding et al., 2016).
In these patients, it is imperative to avoid alcohol consumption as there has been a link between increasing alcohol consumption and increasing the risk of PTE. It can also increase the risk of repeat seizures in patients with a previous history of PTE due to its interactive effects with anti-seizure medications.
Depression and anxiety are the two most common psychological symptoms that are experienced by people after sustaining a TBI, with 1 in 5 people experiencing some mental health-related symptoms up to 6 months after the injury (Stein et al., 2019).
Anxiety and depression are thought to stem from a variety of factors after sustaining a TBI, including worsening of pre-existing mental health issues, post-traumatic stress, removal from regular sports, school and work activities, and other cognitive biases around TBIs.
Alcohol can worsen symptoms of depression and anxiety through a few different proposed mechanisms:
Firstly, alcohol can inhibit the ability of the brain to regulate emotions, which is already impaired after a traumatic brain injury, compounding the problem.
Secondly, as previously discussed, alcohol can increase inflammation in both the brain and liver, which can negatively impact brain function and worsen emotion regulation. These exact mechanisms are seen in those suffering from depression without a brain injury, so it is even more critical to limit this pathway if you have a brain injury (Kelley et al., 2011).
Lastly, teenagers and young adults are particularly susceptible to the link between concussion, alcohol, and mental health difficulties as they may be using substances to self-medicate after being unable to attend their regular school, sports, and social functions due to their injury.
In conclusion, alcohol should be avoided after you have sustained a traumatic brain injury. Alcohol can increase the risk of a second head injury, increase systemic and neuroinflammation, worsen cognitive problems, worsen sleep difficulties, compound symptoms of depression and anxiety, and increase your risk of post-traumatic epilepsy.
There is currently no definitive timeline on when it is safe to go back to consuming alcohol after sustaining a TBI, so this is something that you and your healthcare practitioner should discuss as a part of your plan of management to make sure that you are not inhibiting your brain’s recovery. The current data show us that the only safe amount of alcohol is zero. Still, depending on where you are in your concussion recovery, there may be some level of alcohol intake that can be considered on an individualized basis.
If you are worried about and struggling with your alcohol consumption, please visit the government Canada or United States websites for addiction and mental health services that are available in your area.
https://www.canada.ca/en/health-canada/services/substance-use/get-help-with-substance-use.html
https://www.usa.gov/substance-abuse
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