Management of post-concussion sleep difficulty

Why do these problems happen?

“A concussion weakens your brain’s ability to make and supply energy for healing. To make matters worse, a concussed brain needs more energy than normal to restore balance and heal. This gap between your lower energy supply and higher energy demand explains why you may feel extremely tired after a concussion.  On top of this energy shortage, your brain is prioritizing its limited energy for healing, which means that you have less energy available for daily functioning. It’s common for people recovering from a concussion to feel they are always “running out of energy.””   This very helpful blog post explains exactly what happens in the brain that causes sleep problems and fatigue: What happens to your brain?

How else could this symptom manifest?

• Irritability
• Lack of energy

Are there any helpful medications/supplements?

“Fortunately, your brain can repair and heal itself! It is valuable to remember that your brain can be retrained. Networks between neurons can be reshaped, rebuilt, and strengthened.”  With time, care, and occasionally with medications and natural health products, quality of life and symptoms will get better.  Though this list is not extensive, these are a few medications/supplements to discuss with your concussion provider that may be helpful for your child’s sleep difficulty:

• Omega-3’s (while not targeted to a specific symptom, helpful in overall concussion recovery)
• Multivitamin (If lacking a well-balanced diet, a daily multivitamin is important since good nutrition is essential for healing. Also, it’s important to have adequate Vitamin D levels at baseline as Vitamin D deficiency can lead to prolonged recovery - More info on Vitamin D. )
• Melatonin or Melatonin XR (XR version is more helpful if difficulty staying asleep)
• Magnesium

The FDA does not regulate Natural Health Products (NHP’s) in the same way as prescription medications and therefore when choosing a NHP it is important to consider interactions with other NHP’s and medications, whether the product has undergone 3rd party testing (like that done by Consumer Lab), and the number of ingredients in each product.   The companies we typically trust, because they conduct 3rd party testing and have fewer added ingredients include:  Metagenics, Pure Encapsulations, Nordic Naturals, Barleans, Kirkland Signature, NatureMade, and Neurobiologix. 

What else can we do?

1. Encourage your child to listen to his/her body. If he/she is feeling very tired, taking breaks more often will be helpful.  Listening to his/her body, rather than “pushing through” an activity despite feeling more and more fatigued, will greatly help recovery.  An easy rule of thumb is not let their eye symptoms reach a number >5/10.  So, if for example they start their day with fatigue rated 2/10 and being in the school environment causes it to go up to a 4/10, it’s okay to keep pushing; however, if that fatigue reaches to a 5 or greater, stop and take a break. 
2. Sleep hygiene is especially important, and this starts with a consistent bedtime routine. Staying off of electronics at least 30 min-1 hr. before bed helps facilitate sleep. Sleeping in a cool, dark room, and listening to white noise or a fan, may be helpful as well. 
3. Avoid naps!  Though of course rest is helpful for concussion recovery, we’d rather your child go to bed a little earlier to get a solid 8-10 hours of sleep than get those 8-10 hours by napping during the day.  Of course, if your child is exhausted after school and needs a brief nap, that is totally fine, but we recommend keeping it brief. Napping multiple times/day or more than 1 hour at a time, may help in the short term, but then can make it more difficult to sleep well at night.   
4. Keep a routine. It is really helpful to keep a routine that is close to what was done before the concussion, allowing for breaks and changes in the routine if symptoms greatly worsen.  So, getting up at the same time each day and going to bed at the same time is helpful – though the wake up time may be a little later than baseline and bedtime may be earlier.  Trying to attend school (with accommodations) helps the child feel more normal, because he/she is doing her usual activities (again, with accommodations as needed).  Eating 3 meals/day at regular intervals, whether hungry or not, is important.  Good nutrition is essential for healing.
5. Exercise is important.  To ask a student who regularly plays soccer for 1 hour/day 5 days a week to stop all exercise during concussion recovery is not helpful.  This does not mean he/she should continue to scrimmage or play in games, but continuing to do light, non-contact exercise, as long as it is not worsening symptoms, is helpful (when certain parameters have been met).  Exercise helps maintain the regular routine, keep him/her in shape for return to sports when well, improve mental health, and promotes good sleep.  
6. Though parents know our children so well, we can’t read their minds. To complicate things, their concussion symptoms are often not obvious us, unless they are specifically verbalized outload.  Because of this, it can be easy to doubt that they truly feel the symptoms they are reporting.  It is so important that we validate them, letting them know that that we believe them. Then, it is important to encourage them that these concussion symptoms will resolve and that they will return to normal.

Most children recover from a concussion in 3-4 weeks, and during that time, symptoms typically improve very gradually.  If this is not the observed trend, or symptoms are worsening, it is very important to talk to your concussion provider. 

References: https://www.cdc.gov/traumaticbraininjury/pdf/pediatricmtbiguidelineeducationaltools/2018-mTBI_Recovery-508.pdf

https://www.concussionalliance.org/what-happens-to-your-brain