Concussions and Sleep

Definition

 
A concussion is a mild traumatic brain injury (TBI), caused by head trauma such as a blow, fall, shake, or bump. The trauma to the head might have no outward signs, but it causes a transient and sudden change in brain function.

In a concussion, physical trauma makes the brain move back and forth quickly within the skull, leading to chemical changes and brain cell dysfunction. The brain cells might sometimes stretch, become damaged, or even die altogether.

People with concussions experience a wide range of symptoms. They may be confused or experience nausea, vomiting, memory loss, and problems with judgment, as well as issues with coordination, balance, reflexes, and speech, among others.

Concussions are commonly discussed as “minor” or “mild” injuries, but they can sometimes have serious, far-reaching effects. Concussions are the most common type of TBI, which is one of the leading causes of disability and injury-related death in the U.S.

Because head trauma can result from a wide variety of injuries, concussions are common among every age group. Although the majority of people who have experienced a concussion will fully recover, concussions can sometimes have lifelong effects on brain function.

Recovering from a concussion requires healthy, adequate sleep. But concussions can also disrupt and disturb sleep, which in turn can halt the necessary healing process. This article will cover what a concussion is, how it affects sleep, and the steps you can take to jumpstart the recovery process and improve sleep health after a head injury.

Causes

Since concussions are caused by head trauma, they are especially common among athletes, particularly those who play contact sports, and among military service members. They can also be caused by physical violence, car accidents, or work injuries.

Each year, around 1 million mild traumatic brain injuries occur. Over half of these occur among children, who often get mild TBIs playing sports or participating in recreational activities like snowboarding, skateboarding, and skiing. Because concussions aren’t visible on CT scans or MRIs, they often go undetected–about half of the time, in fact.

Concussions are especially common for people who play contact sports. Approximately 1.7 million to 3 million sports-related injuries occur each year in student athletes. In terms of concussions, football, girls’ soccer, and girls’ basketball are the most likely culprits. Each year, about 20% of student athletes will experience a concussion.

Falls, especially for older adults, are the leading cause of all TBIs. Nearly half of emergency room visits, deaths, and hospitalizations related to TBIs are caused by falls.

Symptoms

Not every concussion will have symptoms, and many concussions will only have mild symptoms. Patients may not experience symptoms right away, but they might show up in the following weeks or even months after a mild TBI. Most symptoms will resolve in a few weeks, but for some patients, they will last longer.

Symptoms of a concussion can include the following:

  • Convulsions or seizures
  • Nausea and vomiting
  • Persistent headaches
  • Drowsiness or trouble waking up
  • Confusion
  • Weakness, lack of coordination or numbness
  • Slurred speech
  • Loss of consciousness

How do Concussions Affect Sleep?

Sleep is important when recovering from a concussion, but suffering a concussion can make it very difficult to get the vital sleep you need.

Sleep disturbances are some of the most common symptoms reported by people with recent mild TBIs. Anywhere from 30-70% of patients with mild TBIs report reduced sleep, poorer sleep quality, and other sleep-related conditions and symptoms in the days and weeks following a concussion. Occasionally, patients even experience insomnia and other sleep disturbances for up to three years after a concussion.

Amount of sleep of concussed individuals vs. average

This chart demonstrates differences in the average amount of sleep people with concussions get versus normal. See the full study here

Sleep disturbances among people with concussions vary widely. It’s common for people with recent concussions to report hypersomnia (excessive sleepiness) in the initial days and weeks following the injury. They may need more naps than usual and feel fatigued throughout the day.

After the initial sleepiness that often follows a concussion, it’s common for patients to report disruptions in circadian rhythms, insomnia, and fatigue for up to a month after the injury. These disruptions may include frequent wakings during the night, poor sleep quality, difficulty falling or staying asleep, and ongoing daily fatigue. Symptoms like pain and headaches, nausea, vomiting, and other common issues associated with concussions often contribute to and exacerbate these sleep disturbances.

Other sleep conditions, like narcolepsy, parasomnias, restless legs syndrome, and sleep apnea sometimes occur after concussions, but these are rare complications of mild TBIs.

Common Post-Concussion Sleep-Related Issues

  • Insomnia: Insomnia is defined as difficulty falling asleep or inability to fall asleep for three nights a week or more for at least three months. Insomnia may continue for just a few weeks after a concussion, but some patients report that it continues for several years after the injury.
  • Fatigue: Fatigue involves extreme daytime sleepiness and restlessness. Fatigue often results from concussions due to symptoms of exhaustion, stress, and insomnia.
  • Sleepiness, or mild hypersomnia, is most common in the first days after a concussion. However, recent research has indicated that daytime sleepiness occurs in a majority of people who have had a concussion for up to 18 months following the initial trauma.

Less Common Post-Concussion Sleep Issues

  • Narcolepsy: Narcolepsy, or major hypersomnia, can involve either sudden muscle weakness and inability to move (cataplexy) accompanied by excessive daytime sleepiness, or excessive daytime sleepiness alone. The latter is more common after a concussion, while the former is more rare.
  • Sleep Apnea: Sleep apnea is a condition that leads to poor sleep quality due to airflow obstructions during the night. This can cause snoring, gasping, wakefulness, and choking during the night. Concussions sometimes lead to sleep apnea, but this complication is relatively rare.
  • Restless Legs Syndrome: Restless legs syndrome is a sleep condition that causes an unpleasant “pins and needles” sensation in the limbs and an overwhelming urge to move the legs when the person is trying to sleep. It can occasionally occur after a concussion, especially if the patient’s iron levels are low.
  • Parasomnias: Parasomnias are atypical, undesirable behaviors that occur during sleep. These behaviors can include sleepwalking, bedwetting, and symptoms of REM sleep behavior disorders like kicking or punching during sleep. Parasomnias rarely manifest as a result of a concussion.

A period of depression and anxiety may also follow a mild TBI, as brain cell damage influences mood and behavior. Depression and anxiety often cause sleep disturbances like insomnia, which can further exacerbate the effects of concussions on sleep health.

Delta and Alpha Waves

Types of brain waves

Brain wave types and their correlated mind-state from Neurofeedback Alliance

Further research into the connection between concussions and sleep health has revealed even more complex and intricate links. One study found that although the concussed group reported more sleep problems than the control group, there were no objective differences observed during sleep through a brain scan.

Instead, they found that during wakefulness, the concussed group produced more delta waves (associated with deep sleep) and less alpha waves (associated with relaxed wakefulness).

This suggests that concussion produces more problems with wakefulness than with sleep. These disturbances in wakefulness can, in turn, lead to additional fatigue and sleep problems.

Rules on Sleeping with a Concussion

Should You Sleep After Getting a Concussion?

A common belief is that you cannot sleep right after getting a concussion. However, depending upon the severity of the injury, this may not necessarily be the case. In fact, a recent study found that young athletes who have good quality sleep after a concussion are more likely to recover within two weeks.

Before sleeping, though, you must take certain factors into account. Your doctor will determine the severity of the concussion and if it is safe to sleep by considering what other symptoms are present.

If you have symptoms such as an inability to hold a conversation, an inability to walk, or dilated pupils, then you should not go to sleep.

In certain instances, it may be safe to sleep despite these symptoms, but it’s always best to consult with a physician after sustaining a concussion in order to determine the best course of action for your specific situation.

The Importance of Sleep After a Concussion

Long-term, the most effective treatment for concussion is rest and sleep. One recent study showed that post-concussion athletes reported more symptoms and a lower score on neurocognitive tests when they got fewer than seven hours of sleep per night.

Quality rest, reduction of screen time, limited exposure to bright lights and loud sounds, avoidance of unnecessary movements of your head and back, and hydration have all been found to help with concussion recovery.

Chronic Traumatic Encephalopathy (CTE) and Sleep

What is CTE?

Chronic traumatic encephalopathy is a neurodegenerative disease caused by repeated head injuries. CTE often gets worse over time and can result in dementia or other neurodegenerative diseases. Many documented cases occur in athletes involved in contact sports, such as football, ice hockey, rugby, soccer, and boxing. In fact, when research into the condition first began during the 1920s, it was known as dementia pugilistca, or “punchdrunk syndrome.”

Contact sports are not the only risk factor for the condition. CTE also often affects people in the military, victims of domestic violence, and others who sustain repeated head injuries.

The exact rate of trauma required for the condition to occur is unknown, although studies have found that about 30% of individuals with a history of multiple head injuries are afflicted by the disease.

Symptoms, which typically do not begin until years after the injuries take place, include confusion, memory loss, erratic or aggressive behavior, impaired balance and motor skills, personality changes, depression, and problems with attention span and organization of thoughts.

Concussions and CTE

Concussion and chronic traumatic encephalopathy are related yet very different conditions. Both are brain injuries, and there may be a relationship between the two conditions. But they differ greatly in time and scope.

A concussion, as we’ve discussed, is a traumatic brain injury resulting from an impact to the head, causing the brain to shake within the skull. Recovery from a concussion takes time, proper treatment, and rest. CTE, on the other hand, is a progressive brain disease with no known cure. It results from repeated traumas to the head and brain.

A large portion of those with CTE are found to have other degenerative brain diseases as well. The symptoms of degeneration of cognitive function typically begin showing up between the ages of 40 and 50. Treatment usually focuses on managing symptoms.

How CTE Affects Sleep

Generally, CTE affects sleep in the same ways as milder cases of traumatic brain injury, like concussions. Studies have found that sleep disturbances affect 30 to 70% of individuals following a TBI. These rates are similar for those suffering from CTE.

Relationship of TBI Sleep-Related Issues

Treating post-TBI sleep disorders requires attending to other underlying diagnoses such as depression or anxiety

The most frequent sleep complaints associated with CTE are insomnia, fatigue, and sleepiness. Narcolepsy, sleep apnea, restless leg syndrome, and parasomnias also may occur, but are less common.

In addition, depression, anxiety, and pain are common with CTE and may have a substantial influence on sleep quality. Even though concussions are acute brain injuries and CTE is a progressive disorder, they are often similar in affects and symptom management.

How Sleep Affects CTE

There is evidence to suggest that sleep disturbances such as obstructive sleep apnea (OSA) and insomnia could be potential risk factors in the development of CTE. Studies of retired and active NFL football players found that the prevalence of OSA ranges from 14% to 19%.

OSA and insomnia have adverse effects on sleep and have been linked to degeneration, leading to progressive CTE. Because sleep is essential for proper brain functioning, it is important that anyone who suspects they may have an issue with their brain get adequate sleep.

Tips for Sleeping with a Concussion

Sleep and rest are key to healing from a concussion. Here are a few important things to know about getting optimal rest after head trauma.

Resting

The best available treatment for a concussion is rest. This includes both mental and physical rest. Sleep is paramount to your recovery process after head trauma. People who don’t get adequate rest after a concussion are likelier to experience symptoms longer, and to experience more severe symptoms, than people who sleep enough during the recovery process.

One of the key aspects of healing from a concussion is mental rest. This includes turning off electronics like video games and computers, avoiding mentally taxing activities like reading or thinking through complex problems, and steering clear of activities that require memory activation or concentration.

Clinicians also recommend avoiding multitasking after a concussion: for example, not reading while watching TV or cooking dinner while texting or taking care of a child. Many people with recent concussions will need to avoid driving for several days. Most people will need some time off of work or school in order to return to full health.

People with a recent concussion should also rest physically, avoiding intense workouts and manual labor (including housework) and any activities that could result in another head injury, such as contact sports. Intense, adrenaline-boosting rides like roller coasters should also be avoided.

Physicians advise that people with recent concussions should sleep well at night and take naps during the day to achieve adequate rest. In all cases, people with a recent concussion should consult a medical professional when deciding how best to recover in the wake of a head injury.

Practice Good Sleep Hygiene

To get adequate rest after a concussion in order to speed up and improve your recovery process, it’s important to practice good sleep hygiene. Good sleep hygiene involves a number of habits and routines that are meant to improve overall sleep health.

  • Know how much sleep you need: Most adults need at least 7-7 ½ hours of sleep per night. Make sure that you set aside enough time to get an uninterrupted block of sleep each night.
  • Go to bed at the same time every night and follow a bedtime routine: Try to go to bed at the same time every night and wake up at the same time every day. This creates a “safe space” around your sleep hours, and promotes a more restful night of sleep.
  • Find a dark, cool, quiet place to sleep: Your bedroom should be an ideal environment for sleep–dark, cool, and quiet. Adjust the temperature, bed sheets, and lighting accordingly, and wear noise-cancelling earbuds if it’s noisy.
  • Dedicate your bed only to sleep and sex: Your bedroom should be a private oasis meant only for sleeping and sex. Try not to work, eat, or do any other activities in your bed.
  • Limit screen time: Turn off all electronics about an hour before you head to bed. Blue lights from smartphones, tablets, and other personal electronics can disrupt your circadian rhythms and disturb your sleep.
  • Eat well, exercise, and get sunshine during the day: It’s important to structure your day so that it prepares you for a good night’s sleep. Eating nutritious foods and getting sunshine are two important parts of every day that will get you ready to rest at night. Some research shows that certain exercises can help with concussion recovery. Studies indicate that 20-30 minutes of light exercise, such as brisk walking, in the first days following a concussion can ease and speed up the recovery process. However, patients should stop if their symptoms worsen after exercise. And as always, consult your doctor if you’re wondering whether it’s advisable to exercise after a concussion.
  • Avoid substances like caffeine and alcohol before bed: Caffeine and alcohol before bed can disturb your sleep, so avoid them in the hours before you head off to rest.

Try Over-the-Counter Sleep Aids

Over-the-counter (OTC) sleep aids are one short-term option for managing sleep loss and disturbances immediately after a concussion. But make sure to check with your doctor before taking any OTC sleep aids to ensure that they’re safe for your particular needs.

Sleep Aid Description Availability Side Effects
Sleep Aid

Antihistamines

Description

Antihistamines are used to treat allergic reactions. They also cause drowsiness. They include medications like doxylamine (Unisom) and diphenhydramine (Benadryl).

Availability

Over-the-counter

Side Effects

Side effects include dry mouth, dizziness, nausea, drowsiness, and difficulty concentrating.

Sleep Aid

Melatonin

Description

Melatonin is a hormone that regulates sleep. It is also available in supplement form.

Availability

Over-the-counter in the U.S.

Side Effects

Melatonin can disrupt hormonal regulation. It lowers sperm count and motility in men. In high amounts, melatonin can cause hypersomnia.

Sleep Aid

Sleep Teas

Description

“Sleep teas” are caffeine-free herbal teas that claim to improve sleep. Chamomile tea and valerian tea are the most popular.

Availability

Health food stores, online

Side Effects

Chamomile tea can cause allergic reactions and is a blood thinner. Valerian root can be addictive.

Sleep Aid

CBD

Description

CBD oil, or cannabidiol, is one of the chemical compounds found in cannabis. It helps with pain relief, relaxation, and sleep.

Availability

Check your local laws to ensure legality.

Side Effects

Side effects can include fatigue, dizziness, changes in appetite, diarrhea, and dry mouth.

Conclusion

Concussions are common traumatic brain injuries (TBIs) that occur as a result of head trauma or injury. They are especially common for athletes who participate in contact sports, as well as after falls, car accidents, and other forms of trauma. Concussions disproportionately affect children and older adults, but they happen across all age groups.

Concussions cause brain cell damage and dysfunction. They lead to symptoms like memory loss and changes in behavior and thinking that may last days, weeks, months, or even years in severe cases.

In terms of sleep, concussions can cause a number of both short-term and long-term disturbances, from insomnia, fatigue, and hypersomnia to narcolepsy, restless legs syndrome, and sleep apnea. Repeated concussions can lead to chronic traumatic encephalopathy (CTE), a neurodegenerative disease that can lead to dementia and causes the same sleep problems as a concussion.

After a concussion, patients should aim to get both mental and physical rest to put them on the road to recovery. They can do this effectively by practicing good sleep hygiene habits, turning off electronics and avoiding mentally taxing activities during the day for a period of time, and, if needed, taking over-the-counter sleep aids under their doctor’s supervision.

Additional Tuck Resources

Here are some other related resources at Tuck to help you on your path to better sleep health if you’re struggling with a recent concussion or related conditions: