Guidelines Quick Access
Sleep Disturbance and Fatigue
More than 50% of people report sleep disturbances following mTBI/concussion, specifically symptoms that may indicate insomnia, hypersomnia, obstructive sleep apnoea, poor sleep maintenance, poor sleep efficiency, early awakening, delayed sleep onset, or alterations in circadian cycle.260-265 While the need for sleep may increase in the immediate acute stage of mTBI/concussion,260 this decreases over time. The key is to recognise sleep disturbance and its cause.
Insomnia is the most common form of sleep disturbance reported in the subacute and chronic stages of mTBI/concussion, occurring in as many as 70% of people especially older adults and women.266-270 Always check for the possibility of other sleep disorders such as obstructive sleep apnoea, restless legs syndrome and depression, treating as appropriate. Simple management strategies for insomnia can help including education about normal sleep and normal waking during sleep and by initiating sleep hygiene measures.
Relaxation techniques such as mindfulness, cognitive behavioural therapy, progressive muscle relaxation, meditation, and breathing techniques can help manage insomnia.271
Sleep monitoring devices such as a sleep diary, and technological solutions for monitoring sleep (e.g. smart watches) can help recognise patterns in sleep habits.274 Sleep trackers (e.g. smart watches) don’t measure sleep directly and this can only be done with a medical sleep study. When used with professional guidance, sleep trackers may aid in assessment of sleep quantity and the efficacy of current treatments in relation to the number of hours of sleep per night, the number of times one wakes up throughout the night, antecedents, and disturbances which may be impacting sleep.274
CBR 267
A repeat medical assessment should be performed for all people presenting with sleep disturbances 1-2 weeks following acute mTBI/concussion. (Children and adults)
CBR 267
People with post-concussion symptoms should be routinely screened for sleep-related problems (i.e. sleep disturbances). For those screening positive, sleep should be evaluated using a validated assessment tool, particularly for insomnia. (Children and adults)
CBR 274
When criteria are met for chronic insomnia, sleep should be monitored for improvement over time using validated person-reported outcome measures or sleep monitoring devices. (Children and adults)
CBR 274
Other pre-existing sleep-wake disturbances and medical conditions that influence sleep should be screened for and treated. Medications that influence sleep (including supplements, herbal medicines or steroid medications) should be noted and their use monitored. (Children and adults)
Further Guidance
The Australasian Sleep Association provides guidance on assessment and management of insomnia that is endorsed by the RACGP.
Sleep disturbance is common following mTBI/concussion, with most people having mild symptoms and achieving full recovery with time.267 While most sleep-related problems will resolve spontaneously, targeted intervention may be required to facilitate recovery.267 Poor sleep may exacerbate other symptoms such as headache, fatigue, mood disturbances and cognitive problems possibly contributing to delayed recovery.268, 275, 276 Targeted treatment of sleep disturbances, alongside other more disabling symptoms of headache, fatigue and mood is likely to improve overall recovery.
EBR (Conditional) 201,222,264,266,270,275,277-284
Education and treatment of sleep disturbances (including sleep apnoea) should be prioritised (along with headache and mood), given their significant impact and interaction with other functionally limiting symptoms. (Children and adults)
CBR 267,268,275,276
Education on sleep disturbances should be provided in written, verbal and/or pictorial formats. (Children and adults)
CBR 287
People with insomnia should be given advice on sleep hygiene (see Box E) and self-management strategies or programs. (Children and adults)
Further Guidance
Further information on providing education about sleep disturbance is available from the RACGP.
Supplements
Melatonin is a natural hormone supplement that is used to adjust the body's internal clock, or circadian rhythm. It has been demonstrated to have efficacy in treating sleep problems in children with persisting post-concussion symptoms 285 and adults with traumatic brain injury.286
Several supplements have been found useful to promote sleep. Magnesium can cause drowsiness, which can help people to fall asleep. Additionally, dietary zinc has been shown to help increase the amount of quality sleep.
EBR (Strong) 273,290-292
Advise people with post-concussion insomnia to use melatonin (2-5 mg two hours before bedtime). (Children and adults)
| 30. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. 273. Barlow Karen M, Brooks Brian L, Esser Michael J, Kirton A, Mikrogianakis A, Zemek Roger L, et al. Efficacy of melatonin in children with postconcussive symptoms: A randomized clinical trial. Pediatrics. 2020;145(4). doi: 10.1542/peds.2019-2812. 290. Srisurapanont K, Samakarn Y, Kamklong B, Siratrairat P, Bumiputra A, Jaikwang M, et al. Blue-wavelength light therapy for post-traumatic brain injury sleepiness, sleep disturbance, depression, and fatigue: A systematic review and network meta-analysis. PLoS ONE. 2021;16(2):e0246172. doi: 10.1371/journal.pone.0246172. 291. Bajaj S, Vanuk JR, Smith R, Dailey NS, Killgore WDS. Blue-light therapy following mild traumatic brain injury: effects on white matter water diffusion in the brain. Front Neurol. 2017;8:616. doi: 10.3389/fneur.2017.00616. 292. Raikes AC, Dailey NS, Forbeck B, Alkozei A, Killgore WDS. Daily morning blue light therapy for post-mTBI sleep disruption: effects on brain structure and function. Front Neurol. 2021;12:625431. doi: 10.3389/fneur.2021.625431. |
Adapted30 |
EBR (Conditional) 290-294
Advise on reduced evening light exposure and consider bright light exposure or blue light therapy in the morning. (Children and adults)
Practice Points for Sleep Problems After MTBI/Concussion
- Maintain a high index of suspicion for sleep problems.
- Screen for obstructive sleep apnoea and depression as cause of poor sleep.
- Assess sleep using a sleep diary over 2–3 weeks.
- Encourage physical activity.
- Avoid using benzodiazepines.
Further Guidance
Additional resources are available from RACGP HANDI Interventions: Cognitive Behavioural Therapy- Chronic Insomnia; Sleep Therapy Australia; the Sleep Foundation and ThisWayUp.
Cognitive Behavioural Therapy (CBT)
Cognitive behavioural therapy (CBT) is the treatment of choice for sleep-wake disorders following mTBI/concussion.287-289 If CBT provided by a licensed health care professional is not available, remote delivery of CBT and self-management strategies are also effective to reduce sleep wake disturbances. CBT for persistent insomnia incorporates:
- Sleep restriction: limiting time spent in bed during the day
- Stimulus control: build associations between the bedroom and sleep
- Relaxation: e.g. deep breathing, progressive muscular relaxation
- Cognitive therapy: address thoughts, beliefs, and attitudes related to sleep and consequences of sleep problems
- Meditation
EBR (Conditional) 287,288
Refer people with prolonged post-concussion insomnia for cognitive behavioural therapy (CBT) specifically for sleep or to a sleep physician (where accessible). (Children and adults)
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30. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org. |
Adapted 30 |
Pharmacological Treatment
Short-term pharmacological treatment options can be used in people with post-concussion sleep disturbances to establish a more routine sleep-wake pattern using agents with minimal risk of dependency and adverse effects. Medications with anti-cholinergic effects may worsen cognitive deficits, especially in older people.
Further Guidance
For virtual CBT resources, please view the following: Shut-I: Online application offering CBT-I, CBT-I coach, Sleep Foundation.
Additional resources are available from the Western Australian government, Sleep Therapy Australia, ThisWayUp, and Calm.
CBR
If non-pharmacological treatment options have not been effective in treating sleep disturbances that persist beyond 4 weeks, medications could be considered to facilitate sleep. The following principles must be considered: (Children and adults)
- Avoid medications that may lead to dependency or sleep disturbances
- Avoid benzodiazepines
- Aim for a short duration of use
- Recognise potential adverse effects/interactions of medications
- Avoid polypharmacy where possible
- Prescribe medications that may manage multiple co-occurring symptoms (e.g. Amitriptyline for headache and sleep disturbances)
- Start at a low dose and gradually increase as tolerated.
Receiving adequate sleep has been shown to facilitate health140 and, when not adequate, adversely affects medical conditions, including TBI.129-131 Maintenance of appropriate sleep and the management of disrupted sleep may be a critical target of treatment for the people with mTBI/concussion.132-134.
EBR (Conditional) 129-134
If sleep problems emerge or continue despite appropriate sleep hygiene measures, qualified health care professionals may consider referral of people with mTBI/concussion to a sleep disorder specialist or a complex mTBI/concussion management team. (Children and adults)
Fatigue may be perceived as a lack of mental or physical energy which may impair daily functional activities. A standardised scale is appropriate when symptoms of fatigue are suspected. Symptoms of fatigue following mTBI/concussion are common295 and are associated with a constellation of disabling symptoms which may lead to poor outcomes post-injury.296, 297 298 Acute fatigue can be associated with mTBI/concussion. Fatigue that lasts longer than 4 weeks requires further assessment for medical and psychological comorbidities. The management of acute fatigue or chronic fatigue where comorbidities have been excluded should include the management of insomnia, and encourage gradual return to activities of daily living, maintenance of interpersonal relationships, and return to school and work and activity. Exercise, mindfulness-based stress reduction, cognitive behavioural therapy and blue-light therapy may be helpful in treating fatigue.
Due to the complex interplay of concurrent symptoms, fatigue may persist and be exacerbated by an array of other contributing factors. These may include mood disorders, sleep disturbances, post-traumatic migraine, metabolic diseases, endocrine disorders, cognitive slowing, electrolyte abnormalities,299 consequences of adverse effects of medications and supplements,300 polypharmacy, alcohol, substance use, and/or nutritional deficiencies.30
CBR 267
A repeat medical assessment should be performed for all people presenting with sleep disturbances 1-2 weeks following acute mTBI/concussion. (Children and adults)
Further Guidance
Additional information on assessment of fatigue is available from the RACGP and BMJ Best Practice.
Various behavioural management strategies may be employed to reduce symptoms of fatigue in people with mTBI/concussion.302 For example, distributing activities and breaks across the day may assist people to achieve more without exceeding tolerance levels.298, 302 This may be facilitated with the use of a notebook or diary to plan and record activities. Self-monitoring and planning may also aid in identifying patterns of fatigue and contributing factors.302 Good sleep management strategies, such as regular sleep-wake schedules and avoidance of stimulants and alcohol may also be of benefit.
EBR (Strong) 287,302-303
People with significant symptoms of fatigue should be given information about management of contributing factors (see Table 4). (Children and adults)
Melatonin
Melatonin is a natural hormone supplement that is used to help regulate the body's internal clock, or circadian rhythm. Taking 2–5mg of melatonin 2 hours before bedtime can help restore sleep and improve daytime alertness.303
EBR (Conditional) 303,305
Advise people with fatigue resulting from disturbed sleep to use melatonin (2-5 mg two hours before bedtime). (Children and adults)
Cognitive Behavioural Therapy
Mindfulness-based stress reduction and cognitive behavioural therapy can be used successfully to address fatigue as well as sleep disturbance following traumatic brain injury.289, 304 Such therapy focuses on monitoring and adjusting the daily routine to intersperse periods of activity with rest, often requiring adjustment of ways of thinking about activity levels, and learning specific strategies to manage cognitive slowing.
EBR (Conditional) 303,305
Cognitive behavioural therapy and mindfulness-based stress reduction should be considered when managing fatigue. (Children and adults)
Blue Wavelength Light Therapy
Daily morning blue light therapy for 30 minutes over the course of 6 weeks may reduce daytime sleepiness following mTBI/concussion.290, 294 A GP can guide this therapy.
CBR 290,292,294
Blue light therapy may be considered to reduce symptoms of fatigue and excessive daytime sleepiness.
Interdisciplinary approaches to mTBI/concussion treatment may be effective. People with post-concussion fatigue may benefit from referral to an interdisciplinary mTBI/concussion team wherein practitioners from multiple disciplines coordinate care by providing diagnostic, educational, physical, cognitive, functional and emotional support.177, 235-237 Interventions that may be effective in individuals with symptoms of fatigue include cognitive behavioural therapy, psychoeducation, psychotherapy, and exercise.219
EBR (Conditional) 303
Referral to interdisciplinary concussion team or an appropriately qualified health care professional should be considered if fatigue causing functional impairment persisting for more than 4 weeks. (Children and adults)
Further Guidance
Additional resources to assist with sleep/fatigue include the “Four Ps”, “strategies to promote good sleep and alertness” and “Sleep for Youth”.