The Myth of Avoiding Sleep After Concussion
You ARE supposed to sleep after a concussion—the old advice to keep someone awake is outdated and potentially harmful. This misconception stems from historical concerns about missing signs of deteriorating brain injury, but modern evidence shows that adequate sleep is actually essential for concussion recovery.
Why Sleep Is Essential After Concussion
Sleep disturbances are common after concussion and can significantly impair recovery. Sleep dysfunction arises primarily from the brain injury itself and secondarily from other concussion-related symptoms 1. Sleep disturbances adversely affect recovery from concussion regardless of whether they existed before or were caused by the injury 1.
Impact on Recovery Outcomes
- Sleep disturbance following concussion is associated with a 3- to 4-fold increase in recovery time in adolescents 2
- Trouble falling asleep is independently associated with higher symptom burden, more missed school days, and worse clinical outcomes 3
- Younger children (6-11 years) show transient alterations in daytime sleepiness that correlate with overall concussion symptom severity 4
The Real Concern: Monitoring for Serious Injury
The historical advice to avoid sleep was based on the need to monitor for signs of intracranial injury, not because sleep itself is harmful. The actual concern is missing deteriorating neurological status from complications like intracranial bleeding 1.
When to Seek Emergency Care
- Children with severe or worsening headache after concussion are at moderate risk for intracranial complications and require immediate evaluation 1
- Warning signs requiring immediate medical attention include sudden severe headache, repeated vomiting, increasing confusion, or altered consciousness 1, 5
- The solution is appropriate initial evaluation and monitoring—not sleep deprivation 1
Current Evidence-Based Recommendations
Promote Proper Sleep Hygiene
Health care professionals should provide guidance on proper sleep hygiene methods to facilitate recovery from pediatric concussion 1. This represents a moderate level B recommendation from the CDC guidelines 1.
- Adequate sleep facilitates health and recovery, while inadequate sleep adversely affects medical conditions including traumatic brain injury 1
- If sleep problems emerge or continue despite appropriate sleep hygiene measures, referral to a sleep disorder specialist should be considered 1, 5
Cognitive and Physical Rest
- "Cognitive rest" is recommended to prevent symptom exacerbation, which may include temporary modifications to school attendance and workload 1
- After a concussion, all athletes should have physical rest initially, though strict prolonged bed rest has been found ineffective or potentially detrimental 1
- Activities requiring concentration (video games, computer use, television) should be limited if they exacerbate symptoms 1
Common Pitfalls to Avoid
Do not confuse the need for monitoring with the need to prevent sleep. The appropriate approach is:
- Initial assessment: Evaluate for signs of serious intracranial injury requiring imaging 1
- Appropriate monitoring: If concerning features are present, obtain neuroimaging rather than preventing sleep 1
- Promote recovery: Once serious injury is excluded, encourage adequate sleep as part of the recovery process 1
Sleep as Part of Multidisciplinary Management
- Sleep disturbance often occurs alongside other concussion subtypes including anxiety/mood, cognitive, and headache symptoms 1
- Nonrestorative sleep can cause fatigue and daytime drowsiness that compounds other concussion symptoms 1
- For persistent sleep problems, melatonin has shown effectiveness in improving sleep disturbance in 67% of adolescent concussion patients 2
The bottom line: Sleep is therapeutic after concussion, not dangerous. The outdated practice of keeping concussion patients awake has been replaced by evidence-based recommendations that emphasize proper sleep hygiene and appropriate monitoring for serious complications 1.