Medical follow-up
(Sleep disturbance >1-4 weeks)
- Screen for medical conditions, current medication use, comorbid psychopathology, and risk factors for sleep disturbances (Sidebar 1)
- Reinforce the importance of sleep hygiene and physical and cognitive activity
- Assess return to school and return to sport status
- Consider treating with cognitive behavioural therapy (CBT) or refer to interdisciplinary concussion team if symptoms last longer than 4 weeks (or sooner as needed/using clinical judgment)
Sleep disturbances persist > 6 weeks post-concussion and interventions at 4-weeks have been unsuccessful
Cognitive behavioural therapy or referral to healthcare professionals/interdisciplinary concussion team
- Cognitive behaviour therapy (CBT): treatment of choice
- Daily supplements: magnesium, melatonin, and zinc
- If CBT is not available: monitor behavioural interventions weekly, consider referral to an interdisciplinary concussion clinic or occupational therapist
Refer to a sleep specialist for consultation Particularly if sleep hygiene can’t be optimized and poor sleep quality is impacting ability to return to school or ability to recondition. Ideal specialist: a specialist who has experience with mTBI and polysomnography.
Pharmacological treatment
Consider prescribing medication on a short-term basis if sleep has not improved > 6 weeks postinjury. Ensure that medications do not result in dependency and that patient has minimal adverse effects. The aim is to establish a more routine sleep pattern. (Sidebar 2)
Refer to a sleep specialist for consultation Particularly if sleep hygiene can’t be optimized and poor sleep quality is impacting ability to return to school or ability to recondition. Ideal specialist: a specialist who has experience with mTBI and polysomnography.
Refer to a sleep specialist for consultation Particularly if sleep hygiene can’t be optimized and poor sleep quality is impacting ability to return to school or ability to recondition. Ideal specialist: a specialist who has experience with mTBI and polysomnography.
SIDEBAR 1
Factors that may influence the child/adolescent’s sleep/wake cycle
>Medical conditions
- Endocrine dysfunction
- Metabolic dysfunction
- Obesity
- Enlarged tonsils
- Obstruction
- Sleep-related breathing disorders
- Early morning headaches
>Current medication use
Verify if patient’s prescribed or non-prescribed medications impact sleep:
- Inadequate medication •Dosage
- Timing of administration
- Screen for stimulants
>Comorbid psychopathology
- Mood and anxiety disorders
- Post-traumatic stress disorder (PTSD)
- Query nightmares and/or night terrors
>Unhealthy habits
- Lack of exercise
- Variable sleep-wake schedule
- Excessive napping
- Excessive time spent in bed
- Exercising close to bedtime
- Screen time
- Use of nicotine, caffeine, energy drinks, processed foods, processed sugars, alcohol and drugs
SIDEBAR 2
Potential medication options – short-term basis only
- Trazodone 12.5 mg
- Amitriptyline 5.0 – 10.0 mg