Sleep and Traumatic Brain Injury

Brian D. Greenwald, MD, MD and Kathleen Bell, MD Model Systems Knowledge Translation Center
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.
  • Create a restful atmosphere in the bedroom, protected from distractions, noise, extreme temperatures and light.
  • If you don’t fall asleep in 30 minutes, get out of bed and do something relaxing or boring until you feel sleepy.

Talk to your doctor

If your sleep problems persist, talk to your doctor to explore safe and effective solutions. Evaluation of sleep problems should include a thorough history of such problems, medication review, an assessment of your bedtime routines, and a comprehensive medical evaluation. Before recommending any action, your physician will explore with you a variety of possible causes for your sleep problems, including pain or depression. If necessary, he or she may recommend a polysomnographic evaluation (also known as a sleep lab). Based on your symptoms, medical history and specific needs, your doctor will be able to make a personalized treatment plan to help you achieve restful sleep.

Treatment options

Non-pharmacological therapies

  • If mood or emotional issues such as anxiety or depression are causing sleep difficulties, psychotherapy (counseling) may be an appropriate treatment.
  • Sleep restriction may improve sleeping patterns by restricting the number of hours spent in bed to the actual number of hours slept.
  • For those with anxiety, relaxation therapy can help create a restful environment both in your bedroom and in your body and mind.
  • Use of special bright lights (phototherapy) has been shown in studies to help promote sleep. When exposed to these lights at strategic times in the day, you may be able to sleep more at night. However, consult with your doctor first, as these bright lights can cause eyestrain and headaches.

Ask your doctor about medications that can help you sleep through the night or keep you awake during the day. Special care is necessary when choosing a medication in order to avoid daytime sedation or worsening of cognitive and behavior problems.

Natural remedies
Some consumers have found herbal teas, melatonin and valerian useful for sleep problems, and these are sold in health food and drug stores with no prescription needed. However, these remedies have multiple drug interactions, and you should tell your doctor if you are using them.

Recommended readings and resources

Our health information content is based on research evidence and/or professional consensus and has been re¬viewed and approved by an editorial team of experts from the TBI Model Systems.

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).

Posted on BrainLine March 25, 2010. Reviewed July 26, 2018.

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 (24)

Please remember, we are not able to give medical or legal advice. If you have medical concerns, please consult your doctor. All posted comments are the views and opinions of the poster only.

i have tbi depression anxiety and soical anxiety and i am only 13 and i have a phycotic breakdown likei chased my brother with a knife sayingi am going to kill and i don't know if i have any other condtions i dont know about please can someone tell me cuz i have mood swings at school and home the reason why i have mood swings at school it cuz the teacher mak me really really really angry so i kick of then and home i swear, i say stuff i don't mean and i smash up things

I'm 58 ,borne with ATAXIA. Since 2009 , I have had 17 concussions. SEIZURES, 3 yrs. I
Have herniated disc. I fall asleep, 1 hr @ nite.Bingo! 1hr ,I wake up, crying, or saying mumbo jumbo. I hate it, I have always been able to control my bipolar / meds etc
I cannot climb over this!

I had head injury 20 years ago I had 5 seasers this last year I have a hard time sleeping I get confused a lot my work bounces my hrs I don't know what to do

I was in a bad car accident almost 5 months ago with TBI. I can't fall asleep but when I do go to sleep, I can sleep up to 12 hours straight. I am on Tylenol with codeine for pain and take trazadone for sleep but not helping as it is 4 am as i am typing. I can go an entire night without sleep. My body is exhausted but my brain jumps between thoughts constantly and keeps me awake. I've tried essential oils with no help.

same how old are u do u get mood swings and lash out

Same. Pot helps best. TBI all my life I believe well since age 4. I had multiple upon multiple throughout the rest of my life to now. No one listens to me. They think I am just trying to get "High". My late mother who had cancer and died. Gave up her medications. I used to take the pain killers or she would give me some for my head aches. She's gone. Currently on opiates but they don't last. Pot isn't legal yet and its the only thing that works and stops the nerve jolts while trying to sleep. Pot is hard to get too. I could list every head injury but that would take a few pages describing all the incidents. Approximate count of head injuries would be by guess; 20 to 40 or more. Little hits or big injuries such as vehicle accidents etc.
You are not alone. I am 9 weeks after mild TBI with post concussion syndrome after being struck by car from behind while cycling. Symptoms did not start until I got out of hospital and impatient rehab (3 weeks total in hospital). Having a horrible time sleeping over last 2-3 weeks, and anxiety level is 9 on a 10 scale with only a few exceptions. I had generalized anxiety disorder and could manage it with Valerian and focused breathing. Now seems anxiety is overwhelming. I know sleep would help, but can't seem to sleep enough in one span to quell it. Returning to work has made it infinitely worse. Hoping Vayacog prescribed by neurologist will help, but takes about 20-30 days to start feeling effect, according to neurologist. Memory is poor, too, and Vayacog supposed to help that, as well.

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?

Sleep, what is that?

Multiple concussions, the last one was three years ago, the bad one was in 2009, and I have not slept since. Drugs do make me sleep, but then I wake up the biggest asshole in the world punching holes and everything. And they don't work for many nights in a row. Cannabis works if you take enough of the oil, then sometimes you're just high, and miserable all night. I think those of us that have the courage to finally end life for themselves do so due to sleep deprivation.

I try to eat all organic, went on gaps for years, I have a hyperbaric in the house, I have a Bemer PEMF, and just about everything else you can imagine. Nothing really works there is no hope. Life is a joke.

Hello, I understand your frustration. I have been talking to a neurologist because my husband suffered multiple TBI’s well in the military and it has left him unable to sleep well and when he does sleep he has nightmares and grinds his teeth all night. During the day a lot of the time he is paranoid, can be quite critical and mean. He was a gentle man with hope and so caring. He breaks thing rarely but does hit himself. He is currently seeing the world in a very negative light. I am currently living in another state because he to my knowledge has not been trying to recover himself. However I have been reading and talking to doctors and mental health professionals to learn if he can retraining his brain and despite sever scare tissue in the amygdala and hippocampus he can retrain his brain. He can although it will be hard and requires a lot of determination and willingness he can recover himself and his emotions. This being said I know that retraining your brain can work and if you want to regain your life back I highly suggest working on finding a brain doctor that can help you achieve this.

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!!!

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!

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! ♥️

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

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.

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. 

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

Similar experience, resusitated. My ears would say one thing my eyes another. Eyes trump ears. I use to not sleep for days or hardly at all for weeks. Then I could sleep for several days or 15 hours at a time and not feel rested. It's been 27 years since head injury. I still have nights I cannot sleep, but most nights I can get an average of 4 to 5 hours when I work. I then play catch up on days off when I have a week that is particularly bad. Sleep does improve slowly at least in my situation. I found a powder by you theory at Walmart called Sleep. It helps sometimes. It has L tryptophan, 5 http, and melatonin. It is not a miricle but even a few hours of sleep is better than none. Keeping a schedule helps somewhat too. Good Luck. I believe the brain continues to heal and adapt even 25 years later. Every TBI is different though. Don't give up. I also sleep with TV on most nights. It is suppose to help with alpha wave intrusion during sleep. Try watching something you've seen already or is boring. Noise is just there to distract from active thinking. I hope some of these sugestions help. You could also sleep with a mask.

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.

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!

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.

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


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?

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.