Domain 7: Sleep
Recommendations
7.1
Perform a repeat medical assessment on all patients presenting with post-concussion sleep disturbances 1-2 weeks following acute injury.
Level of Evidence:
Include a focused history, physical examination, and consider diagnostic brain or cervical spine MRI imaging for those with focal or worrisome symptoms.
Screen for factors that may influence the child/adolescent’s sleep/wake cycle and for sleep-wake disturbances such as insomnia or excessive daytime sleepiness.
7.2
Provide general education and guidance on sleep hygiene that outlines non-pharmacological strategies to improve sleep.
Level of Evidence:
7.2a
Continue to encourage patients with sleep disturbances to engage in sub-symptom threshold cognitive activities and physical activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) as soon as tolerated.
Level of Evidence: Gradual return to physical activity.
Gradual return to cognitive activity.
See Recommendation 2.3.
See Tool 2.6: Post-Concussion Information Sheet for examples of low-risk activities.
7.3
Consider managing patients who experience sleep-wake disturbances for more than 4 weeks with cognitive behavioural therapy, treat with daily supplements, and/or refer to an interdisciplinary concussion team.
Level of Evidence:
7.3a
Refer the child/adolescent to a cognitive behavioural specialist. The treatment of choice for primary insomnia and insomnia co-morbid to a medical or psychiatric condition is cognitive behavioural therapy (CBT).
Level of Evidence:
If CBT is unavailable to the patient or the patient is waiting for CBT treatment:
- Optimize and implement sleep hygiene (Tool 2.7: Strategies to Promote Good Sleep and Alertness)
- Monitor the patient weekly for the first few weeks.
- Re-emphasize that patients with sleep disturbances should continue to engage in sub-symptom threshold cognitive and physical activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) as tolerated (Recommendation 2.3).
- Consider referring to an interdisciplinary concussion team.
7.3b
Consider suggesting non-pharmacological supplements such as magnesium, melatonin*, and zinc to improve sleep and recovery without the use of medication that may have side effects.
Level of Evidence:
*Melatonin was not found to be effective when used for youth with concussion symptoms 4-6 weeks after injury in a single-center double-blinded randomized controlled trial” (Barlow et al 2020. Efficacy of Melatonin in Children With Postconcussive Symptoms: A Randomized Clinical Trial. Pediatrics
7.4
Refer patients with prolonged post-concussion sleep disturbances (more than 6 weeks) to a sleep specialist or an interdisciplinary concussion team if the interventions introduced at 4 weeks have been unsuccessful and sleep issues persist.
Level of Evidence:
If sleep issues persist for more than 6 weeks post-acute injury, sleep hygiene can’t be optimized, and if poor sleep quality is impacting the ability to return-to-school or ability to recondition:
- Refer to a sleep specialist who has experience with concussion and polysomnography or to an interdisciplinary concussion team that has the expertise to understand sleep disturbances in the context of concussion-related symptoms.
Consider ordering sleep tests to rule out possible sleep-related breathing disorders, nocturnal seizures, periodic limb movements, or narcolepsy.
- Examples of sleep tests include Sleep Study, Multiple Sleep Latency Test, and the Maintenance of Wakefulness Test.
7.5
Consider prescribing medication on a short-term basis if sleep has not improved after 6 weeks following the acute injury.
Level of Evidence:
Ensure that medications do not result in dependency and that the patient has minimal adverse effects. The aim is to establish a more routine sleep pattern.
- Potential medication options include trazodone 12.5 mg or amitriptyline 5.0 – 10.0 mg.
- Tool 6.2: General Considerations Regarding Pharmacotherapy.
- Tool 6.3: Approved Medications for Pediatric Indications.
If sleep disturbances persist after pharmacological treatment refer to a pediatric sleep specialist ideally with experience with concussion and polysomnography.
7.6
Recommend a medical follow-up to reassess clinical status if sleep disturbances persist. Recommend an immediate medical follow-up in the presence of any deterioration. Consider early referral (before 4 weeks) to an interdisciplinary concussion team in the presence of modifiers that may delay recovery.
Level of Evidence: Medical follow-up.
Early referral in the presence of modifiers that may delay recovery.
Specialized interdisciplinary concussion care is ideally initiated for patients at elevated risk for a delayed recovery within the first two weeks post-injury.
Level of Evidence: B
See Recommendation 2.1b: Note any modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.