How to deal with sleep and fatigue after a concussion

In the acute stages of a concussion, a series of biological events that stimulate the neurometabolic cascade (i.e. ionic, metabolic, and physiologic events) often get set into motion, which results in an energy crisis.

While fatigue is one of the most commonly reported symptoms post-concussion, it is also one of the most frequently reported problems in healthy adults. Moreover, being fatigued as a result of poor sleep can contribute to cognitive dysfunction.

When it comes to concussion management, sleep is crucial, as lack of sleep hinders recovery. Furthermore, decreased sleep leads to a reduction in reaction time, cognitive processing speed, and an increase in anxiety and depression. Doctors who coach athletes on sleep have even proclaimed that, “A 22-year-old NBA rookie will have the testosterone levels of a 33-year-old veteran if he doesn’t sleep.”

Dealing with sleep and fatigue following a concussion

If sleep issues and fatigue persist following the acute and subacute stages of recovery, the following interventions may be considered:

• Gradual return to physical activity (aerobic exercise, 30-60 minutes a day if you feel well enough)
• Pacing
• Mindfulness-based stress reduction techniques
• Acupuncture
• Blue light therapy
• Cognitive-behavioral therapy for insomnia
• Supplements, such as magnesium or zinc*
• Medications (which should be discussed with a clinician)
  • Low dose trazodone
  • Low dose TCA’s
  • Mirtazapine
  • Prazosin (in case of nightmares and/or PTSD issues)
  • Short term use of Zopiclone
  • If excessive daytime sleepiness: Modafinil, Armodafinil

*Another possible supplement is melatonin, but recent guidelines for the treatment of insomnia do not encourage the use of melatonin for sleep onset or sleep maintenance issues.

Improving sleep hygiene

Maintaining good habits and a regular routine can also facilitate sleep. To improve your sleep hygiene, try to:

• Go to sleep and wake up at the same time every day, without changing your bedtime schedule on the weekends. You can use an alarm to wake up around the same time every day.
   
• Avoid lying in bed and worrying about not being able to fall asleep, which is counter-productive and will only make you feel more anxious. If you can’t fall asleep within 30 minutes, get up and do something relaxing, such as taking a warm bath, reading a book or listening to an audiobook or practicing deep breathing exercises. When you feel sleepy again, go back to bed.
   
• Take only one nap per day (or no nap at all), as napping makes it harder to sleep at night. If you do take a nap, try to limit it to 20-30 minutes and make sure to take it before 3 pm.
   
• Make sure you’re getting enough vitamins and minerals as part of your diet (including magnesium, iron, and B vitamins).
   
• Avoid drinking caffeine or alcohol 4 to 6 hours before bedtime, as it can wake you up in the middle of the night. Heavy meals late in the day can also cause problems. On the other hand, a small bedtime snack that contains protein can help.
   
• Get some natural light during the day.
   
• Avoid exercising before bedtime.
   
• Keep your bedroom quiet, dark, cool and comfortable.
   
• Wear earplugs or use a white noise machine or fan if sounds coming from outside are keeping you awake.
   
• Avoid watching TV, using a cell phone or laptop computer in the bedroom, as lights can make the brain work harder.

If the above interventions do not appear to resolve or curtail your sleep problems, a healthcare professional may also look into other potential issues that may be causing excessive fatigue, such as depression, cancer, thyroid issues, sleep apnea and/or low iron.

For more information about concussion care, check out our Locations page to schedule an appointment with a Lifemark clinician near you.