First-Line Treatment for Post-Concussion Anxiety and Sleep Disturbances
For anxiety and sleep disturbances following concussion, initiate psychological treatment (cognitive behavioral therapy) as first-line for anxiety, and implement sleep hygiene education with consideration of melatonin for sleep problems, while simultaneously addressing these symptoms within a graded physical exercise program. 1, 2
Psychological Treatment for Anxiety
Psychological treatment should be offered as individual or group therapy administered at least 1 hour per week for a minimum of 4 weeks. 1, 2
- This intervention demonstrates positive effects on emotional symptoms (including anxiety), overall symptom burden, and quality of life at longest follow-up 1
- The treatment should be provided by psychologists or clinicians with similar professional backgrounds 1
- Evidence quality is low due to risk of bias and indirectness, but the recommendation is consistent across guidelines 2
Sleep Disturbance Management
Sleep problems require early intervention as they are associated with 3- to 4-fold increase in recovery time and higher overall symptom burden. 3, 4
Initial Sleep Interventions:
- Provide systematic patient education regarding sleep hygiene and expected recovery course within the first 4 weeks post-injury 2
- Consider melatonin supplementation for sleep disturbances, though evidence shows it improves sleep in 67% of patients but does not necessarily accelerate overall symptom recovery 3, 5
- Addressing sleep early is imperative to preventing chronic post-concussion symptoms and maladaptive sleep behaviors 6
Important Clinical Context:
- Sleep disturbances occur in approximately 34-45% of concussion patients 3
- Patients with trouble falling asleep report significantly higher symptom severity (median 38 vs 18 on symptom scales) 4
- Sleep problems are more common in non-sport-related concussions (45%) compared to sport-related (29%) 3
Integrated Physical Exercise Component
Implement sub-symptom threshold aerobic exercise with gradual intensity increases as part of the treatment plan, as this addresses both anxiety and sleep through physiological mechanisms. 7, 2, 8
- Graded physical exercise shows positive effects on emotional symptoms, overall symptom burden, and quality of life 2
- Exercise should be started early and progressed based on symptom response 8
Multidisciplinary Coordination
If symptoms persist beyond 4 weeks or are severe, coordinate treatment from at least two healthcare disciplines (e.g., psychology + physical therapy). 1, 2
- Interdisciplinary coordinated rehabilitation demonstrates positive effects on overall symptom burden, emotional symptoms, physical functioning, and quality of life 1, 2
- This approach should include at least 2 interventions administered minimally once weekly for 4 weeks 1
Critical Pitfalls to Avoid:
- Do not delay sleep assessment - sleep disturbances predict prolonged recovery and should be evaluated at initial presentation 3, 4
- Do not rely solely on melatonin - while it may improve sleep quality in two-thirds of patients, it does not accelerate overall symptom recovery and should be combined with behavioral interventions 3, 5
- Do not overlook comorbid symptom generators - anxiety and sleep problems often coexist with vestibular, cervical, or visual dysfunction requiring targeted interventions 7, 2
- Recognize that 15-20% of patients develop persistent symptoms requiring more intensive intervention 1, 2