More than 50% of patients report sleep disturbances following mTBI, specifically insomnia, hypersomnia, obstructive sleep apnea, poor sleep maintenance, poor sleep efficiency, early awakening, delayed sleep onset, or alterations in circadian cycle. (see Appendix 7.1).^1-5 In the immediate acute stage of mTBI, there may be an increased need for sleep⁶ however this decreases over time and insomnia is the most common form of sleep disturbance reported in the subacute and chronic stages of mTBI. Insomnia is characterized by problems with sleep initiation and/or sleep maintenance that can lead to increases in daytime sleepiness and fatigue.^3,4 Although some research has shown a discrepancy between subjective sleep complaints and objective evidence of sleep disturbance (e.g., obtained via polysomnography), recent data has provided evidence of objectively measured alterations in sleep both in the acute stage and chronic stages of injury.^6,7 Sleep disturbance itself has been shown to be a prognostic factor for functional and social outcomes up to one year postinjury.⁸ Patients may experience circadian rhythm sleep disorders, specifically delayed sleep phase syndrome and irregular sleep-wake patterns. Patients experiencing sleep disturbances after mTBI commonly find these symptoms to interfere with mood, mental capacities, communication, social or leisure activities, or their principal occupation.^9,10 It has also been suggested that sleep disturbance among this population may be associated with impairments on neuropsychological and cognitive-communication tests.^10,11 As is the case with many persistent symptoms following mTBI, sleep disturbances can be secondary to other conditions such as depression, anxiety, PTSD or pain. Recent studies by Suzuki et al 2017¹² and Lavigne et al 2015,¹³ found that patients experiencing pain in the acute phase of mTBI may require more sleep than those without pain.12 Management strategies should take this potential interaction of symptoms into account as it may exacerbate poor attention, memory, language processing and learning capabilities.^9,14-18

A key feature of diagnosis is obtaining a history from the patient to record the TBI, to rule out pre-existing sleep disorders and to document symptoms after the injury.¹⁹ Once a thorough evaluation has been conducted, treatment of sleep disorders within the mTBI population may take the form of both non-pharmacologic and pharmacologic methods. For insomnia, cognitive behavioural therapy (CBT) is recommended as it addresses factors perpetuating insomnia, such as unhealthy sleep hygiene, maladaptive sleep habits, autonomic and cognitive arousal, and dysfunctional beliefs and attitudes about sleep.^20,21 Referral to a professional with training and expertise in CBT for insomnia is ideal, however, while waiting for formalized CBT treatment for insomnia, or if this treatment is not available, behavioral recommendations (restriction of time in bed and stimulus control) can still be implemented by primary care providers with weekly monitoring of the patient for the first few weeks (see Appendix 7.5).^2,22,23 Referral to a sleep specialist is essential to evaluate and treat less common sleep problems associated with mTBI, such as sleep-related breathing disorder (e.g., obstructive sleep apnea), circadian rhythm shift, restless leg syndrome, periodic limb movement disorder, and REM sleep behaviour disorder.

Some benefits of melatonin have been documented for insomnia, daytime alertness, or circadian rhythm difficulties after mTBI,^2,16,23 however recent guidelines for the treatment of insomnia²⁴ do not encourage use of melatonin for sleep onset or sleep maintenance issues. There is still very limited data about the efficacy and safety of sleep medications on patients with neurological impairment, and more controlled trials are needed.^2,25 Caution is therefore recommended when prescribing sleep medications, and the aim should be to use pharmacological agents that will improve sleep-wake patterns but will not produce dependency or adverse side-effects, particularly adverse effects on cognition.²⁶ When prescribing medications the patient should be advised not to drive after taking the medication, and recommended that the patient not have to be somewhere early the next day.¹⁹ Patients should also be advised not to have alcohol in conjunction with the medications.

See Algorithm 7.1, which outlines the key steps for assessment and management of persistent sleep-wake disturbances following mTBI.

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