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.

• Tool 7.1: Managing post-concussion sleep disturbances algorithm. 

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.

• Tool 7.2: Factors that may influence the child/adolescent’s sleep/wake cycle.

7.2

Provide general education and guidance on sleep hygiene that outlines non-pharmacological strategies to improve sleep.

Level of Evidence:  

• Tool 2.7: Strategies to Promote Good Sleep and Alertness. 
• Link: Sleep for Youth. CHEO Sleep Hygiene handout.
• Link: Holland Bloorview Kids Rehabilitation Hospital: Concussion Handbook.

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:  

• Tool 6.3: Approved Medications for Pediatric Indications.

*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.