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Sleep and Traumatic Brain Injury

Comments [14]

Brian Greenwald, MD and Kathleen Bell, MD , Model Systems Knowledge Translation Center

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Research Update: Sleep Medications May Have Unwanted Side Effects

How common are sleep problems following at TBI?

Many people who have brain injuries suffer from sleep disturbances. Not sleeping well can increase or worsen depression, anxiety, fatigue, irritability, and one’s sense of well-being. It can also lead to poor work performance and traffic or workplace accidents. A review of sleep disorder studies and surveys suggest that sleep disorders are three times more common in TBI patients than in the general population and that nearly 60% of people with TBI experience long-term difficulties with sleep. Women were more likely to be affected than men. Sleep problems are more likely to develop as the person ages.

What are types of sleep problems?

Sleep disturbances have been found in people with all severities of brain injuries — from mild to severe. Sleep is a complex process that involves many parts of the brain. For this reason, and depending on the location and extent of injury, many different kinds of sleep disturbances can occur after brain injury.

Common sleep disorders include:

  • Insomnia: Difficulty with falling asleep or staying asleep; or sleep that does not make you feel rested. Insomnia can worsen other problems resulting from brain injury, including behavioral and cognitive (thinking) difficulties. Insomnia makes it harder to learn new things. Insomnia is typically worse directly after injury and often improves as time passes.
  • Excessive Daytime Sleepiness: Extreme drowsiness.
  • Delayed Sleep Phase Syndrome: Mixed-up sleep patterns.
  • Narcolepsy: Falling asleep suddenly and uncontrollably during the day.

Common sleep syndromes include:

  • Restless Leg Syndrome (RLS): Urge to move the legs because they feel uncomfortable, especially at night or when lying down.
  • Bruxism: Grinding or clenching teeth.
  • Sleep Apnea: Brief pauses in breathing during sleep, resulting in reduced oxygen flow to the brain and causing loud snoring and frequent awakening.
  • Periodic limb movement disorder (PLMD): Involuntary movement of legs and arms during sleep.
  • Sleepwalking: Walking or performing other activities while sleeping and not being aware of it.

What causes sleep problems?

The brain directs sleep by putting your body to rest. Injury to the brain can lead to changes in sleep.

Physical and chemical changes
The “internal clock” in the brain controls when people sleep and wake every day. If injured, the brain may not be able to tell the body to fall asleep or wake up. There are chemicals in our body that help us to sleep. An injury can change the way that these chemicals affect the body. If brain mechanisms for starting and stopping sleep are injured, a condition called post-traumatic hypersomnia may result in which a person sleeps many hours more than normal.

Changes in breathing control
Sometimes the brain’s ability to control breathing during sleep becomes altered after a TBI, resulting in periods of apnea (when breathing actually stops for long enough for blood oxygen levels to drop). This is called sleep apnea. Other factors may affect the chance of having sleep apnea such as family history or being overweight.

Medications taken after a brain injury may cause problems going to sleep or staying asleep, or can make people sleepy during the day and unable to participate in activities.

  • Prescription drugs for treating asthma and depression may cause insomnia. Also, stimulants that are meant to treat daytime sleepiness can cause insomnia if taken too close to bedtime. These problems can often be avoided by adjusting the timing of the medication or by substituting a different drug — of course, in consultation with your physician. Many other medications can cause sedation (sleepiness), as well.
  • Most over-the-counter sleep aid medications contain an antihistamine (commonly diphenhydramine) and are not recommended for people with TBI because they may cause disturbances in memory and new learning. Retention of urine, dry mouth, nighttime falls and constipation are also possible side effects of this class of medications.

Daytime sleeping (napping) and physical inactivity
Napping during the day is likely to disturb sleep at night. Inactivity or lack of exercise can also worsen sleep.

Many people who have suffered brain injuries also experience pain in other parts of the body. This discomfort may disturb sleep. Medications taken to relieve pain may also affect sleep.

Depression is much more common in persons with traumatic brain injury than in the general population. Sleep problems such as difficulty falling asleep and early morning waking are common symptoms of depression.

While alcohol may help bring on sleep, drinking alcohol before bedtime is likely to interfere with normal sleep rather than improve it.

Caffeine and Nicotine
Nicotine from tobacco may cause sleep disturbances and is often overlooked. Caffeine can disturb sleep when consumed in the afternoon or evening.

What can be done to improve sleep?

Changes in behavior and environment are the first line to treating sleep difficulties.

Daytime Suggestions

  • Set an alarm to try to wake up at the same time every day.
  • Include meaningful activities in your daily schedule.
  • Get off the couch and limit TV watching.
  • Exercise every day. People with TBI who exercise regularly report fewer sleep problems.
  • Try to get outdoors for some sunlight during the daytime. If you live in an area with less sun in the wintertime, consider trying light box therapy.
  • Don’t nap more than 20 minutes during the day.

Nighttime Suggestions

  • Try to go to bed at the same time every night and set your alarm for the next day.
  • Follow a bedtime routine. For example, put out your clothes for morning, brush your teeth and then read or listen to relaxing music for 10 minutes before turning out the light.
  • Avoid caffeine, nicotine, alcohol and sugar for five hours before bedtime.
  • Avoid eating prior to sleep to allow time to digest, but also do not go to bed hungry, as this can also wake you from sleep.
  • Do not exercise within two hours of bedtime but stretching or meditation may help with sleep.
  • Do not eat, read or watch TV while in bed.
  • Keep stress out of the bedroom. For example, do not work or pay bills there.

Sleep and TBI was developed by Brian Greenwald, MD and Kathleen Bell, MD in collaboration with the Model System Knowledge Translation Center. Portions of this document were adapted from materials developed by the New York TBIMS, the Carolinas TBI Rehabilitation and Research System, and from Picking up the pieces after TBI: A guide for Family Members, by Angelle M. Sander, PhD, Baylor College of Medicine (2002).Copyright © 2010 by University of Washington/MSKTC. 

Please check the MSKTC site for any recent updates on this article.

Comments [14]

Going on 2 yrs since TBI to left orbit.  I am 48 and constantly fatigued.  When I try to sleep I awaken a few minutes before I can get there.  All night this happens.  I tried the usual prescriptions. They seem to work great for a few weeks or months then I am back to the same problem.  Has anyone ever experienced similar problems and is there any hope for normalcy to return?

Dec 11th, 2016 8:32pm

I had multiple TBIs as well as Lyme. Sleep problems is the most life interfering. I took Rx drugs for decades. Then at age 70, my memory and cognition was very poor. Then lost my taste and smell. At first, I had a functional neurological chiropractor treat me. He actually did wonders! But still no sleep. Then diagnosed with "mild cognitive impairment". Also another term for possible pre dementia. Ugh. Tried Neurofeedback. CLEARMIND. And another. Quite helpful. But still no sleep. Finally I gave in. Doing hyperbaric oxygen chamber. Have done 40 treatments. Helping!! Need to do more. I must caution people who use over the counter sleep aids. Some can increase risk of dementia. But of course, the prescription ones do too. Do your research!!!

Sep 16th, 2016 12:37pm

Hello. I appreciate everyone sharing their post TBI experiences. I'm 2.5 months in and still have a complete lack of smell, memory loss, random headaches, etc. What I wanted to ask was if anyone else has experienced periods of insomnia as well as periods where you sleep for almost entire days. Example: yesterday I couldn't seem to stay awake for more than 2 hours at a time. Then I would nap for 1-2 hours. I literally took 5 of these naps yesterday and then could not sleep last night!

Sep 4th, 2016 4:02pm

Melatonin is good. I prefer Midnites. I was in a 4-wheeler accident 16 years ago, and I also was a Glasgow 5. I was in a coma for 14 days & had to relearn everything (including walking & talking). Anyway, my insomnia has gotten progressively worse over time. I am currently 6 months pregnant, and so I'm limited on what I can take. So, I take Children's Benadryl throughout the night, but if I were not pregnant, Midnites would be my choice. You can buy them at Walmart & they're chewable. They put you back to sleep fast, usually for about 3 hours at a time. Good luck! ♥️

May 29th, 2016 11:32am

I suffer from a car accident that resulted in a glasgow coma 5 state. I was 39 yrs of age and am 51. I have no problem sleeping but if I have to use the restroom that is what wakes me up, at the same time it throws my sleep pattern off. I am a commercial truck driver and cannot take prescription drugs I also suffer from the other classic symptoms as in depression/lost days/some memory problems etc etc etc. I would like to know if there is something natural I can take to help with this

Apr 20th, 2016 7:00pm

I suffered a brain injury a couple years ago with something going completely through my head & still there. Before they said I use to sleep a lot & when I slowly came around to somewhat my normal senses... I just been losing so much sleep it seems & even when taking over the counter meds like Unisom & Melatonin... They don't really help unless I'm really tired I think?... It also sucks that I can't remember everything & almost every day for me is a restart like having to know what day it is & what was I going to do & trying go through memories slowly or stuff popping in my head if I'm lucky to get my day going... Life has been different for me ever since but it could also be worst. I rarely go to doctors because they really done nothing for me.

Sep 27th, 2015 9:44am

I sustained an acute subdural haematoma 3 years ago and since then I have been experiencing difficulties in getting to sleep at night. I don't recall ever having trouble sleeping in the past, but now I quite frequently just lie awake all night. I am so tired during the day and I have found myself falling asleep in lectures, at the cinema and even at concerts, which is really embarrassing. I obviously try to keep myself awake, but it's as though I don't have any control over it. I had to attend a training session at work today and during the talk I repeatedly drifted off. I am really hoping that no one noticed because obviously it is not normal and looks really unprofessional. Not sure what to do about this. It's now 5am and I still haven't managed to get to sleep. My body clock seems to be completely out of whack. 

May 3rd, 2015 12:00am

I suffered a brain injury and was brought back to life by paramedics in resus. I am now suffering from non sleeping and my eyes and ears are not registering to my brain Any help would be great. Thanks

Mar 22nd, 2015 7:21pm

Had a head injury with post concussion syndrome in 2004. In following years had increased fatigue, even falling asleep at work. In 2012 I started losing the ability to hold my head up in response to funny things. Then my whole body seemed to freeze up in response to funny things or strong emotion. Went to neurologist and was sent for tests for MS, Myesthenia Gravis and Narcolepsy. Turns out the sleep study and daytime sleep latency test corroborated that I have Narcolepsy. The symptom of my head bobbing and muscles losing strength in response to strong emotion or humor is cataplexy, something that normally happens in REM sleep but is abnormal in narcoleptics. I'm convinced my head injury led to my Narcolepsy, which actually is an autoimmune disorder. I write about it here because it's under diagnosed and people may feel like their going crazy, are often misdiagnosed when they have narcolepsy. There are known cases of narcolepsy that occur as a result of head trauma so it's critical that people with TBI understand the symptoms of narcolepsy in case they have the disease. Other symptoms of narcolepsy include excessive daytime sleepiness, hypnogaugig hallucinations (that occur when falling asleep or waking up) and sleep paralysis. Someone with narcolepsy might only have one or could have every symptom, it varies. It can be treated with medication.

Dec 20th, 2014 1:10pm

I'm a 21 year TBI Survivor and inability to get a solid, deep sleep is, seriously, THE WORST repercussion of TBI! I hate it. I tried Ambien and I slept great for a while, but I started feeling lethargic and my memory was awful (more awful than just normal TBI memory).

I got off Ambien, and a friend suggested "Costco Sleep Aid." For some reason, this really works for me! I practice good sleep-hygeine and use deep, slow breathing to fall asleep. You have to find what works for you!

Nov 5th, 2014 11:20pm

This is something that I still battle with, insomnia, after being a passenger in a car that went into a tree. It's almost been 2 years and now I'm looking forward to getting a car and seeing my own neurologist that can help.

Jul 6th, 2014 11:11am

Interested in aroma therapy. What essential oils did u use?



Jul 4th, 2014 6:54pm

I suffered from a minor head injury 3 weeks ago. I have not been sleeping and have had extreme anxiety. I was on tramdol for a few weeks and I also read that withdraw from this medication can cause insomnia. Any suggestions?

Jul 1st, 2014 8:17am

Thank you for the article! I have suffered greatly with insomnia since my accident 4 years ago and wanted to add aromatherapy as a potential useful treatment. I had to experiment with different solutions, and mixologists before I found what worked for me, but I found it more effective than prescription, over-the-counter, tea and melatonin. Might not work for everyone, but thought I'd throw it out there! Also-I noticed, often, when I was having trouble falling asleep, my breathing felt more rapid than it should be at rest. It helped me to take a few slower, longer, deeper breaths and get totally relaxed.

Jan 6th, 2014 11:14am

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