Posttraumatic sleep disturbance

Muna Irfan MD

Sleep Disorders

Updated 09.01.2023
Released 04.22.1994
Expires For CME 09.01.2026

Posttraumatic sleep disturbance

Author: Muna Irfan MD

See Contributor Disclosures

Editor: Michael J Howell MD

Posttraumatic sleep disturbance

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Introduction

Overview

Sleep disturbances are common after traumatic brain injury, affecting 30% to 84% of individuals, with varying degree of head injury. Not only can they negatively impact neurocognitive rehabilitation, but they also add to morbidity and slow the course of recovery. Several sleep impairments are described including insomnia, fatigue, and excessive daytime sleepiness, which are the most frequent complaints after head injury. Circadian rhythm dysregulation, sleep apnea (obstructive or central), restless leg syndrome, and parasomnias have also been reported after trauma. In addition, depression, anxiety, and pain are common comorbidities with substantial influence on sleep quality and course of recovery. Diagnosis of sleep disorders after traumatic brain injury may involve meticulous history, polysomnography, actigraphy, and multiple sleep latency testing. Treatment is disorder specific and may include pharmacotherapy, light therapy, positive airway pressure, behavioral modifications, or a combination of these. Unfortunately, treatment of sleep disorders associated with traumatic brain injury have met with little success in improving clinical outcomes mainly due to confounding psychiatric and neurobehavioral sequela of trauma. Nonetheless, some recent studies have demonstrated encouraging results, which highlight the need for further research and prospective studies to be able to standardize targeted management approach.

Table 1. Sleep Disturbances Associated with Traumatic Brain Injury

	A. Insomnia
		1. Sleep onset 2. Sleep maintenance
	B. Disorders of hypersomnia
		1. Posttraumatic hypersomnia 2. Narcolepsy secondary to other causes 3. Fatigue
	C. Sleep-related disordered breathing
		1. Obstructive sleep apnea (OSA) 2. Central sleep apnea (CSA)
	D. Circadian rhythm disorder
		1. Delayed sleep phase syndrome (DSPS) 2. Advanced sleep phase syndrome 3. Irregular sleep wake syndrome 4. Non-24 hour sleep disorder
	E. Movement disorder
		1. Restless legs syndrome (RLS) 2. Periodic limb movement disorder (PLMD)
	F. Parasomnia
		1. Non-REM parasomnia 2. REM sleep behavior disorder (RBD)
(65)

Key points

	• Sleep disturbance after traumatic brain injury occurs in 30% to 84% of individuals.
	• Insomnia, fatigue, and sleepiness are the most frequent complaints after head injury.
	• Sleep disturbances impact neuropsychological and cognitive rehabilitation of TBI patients negatively.
	• Diagnosis of sleep disorder after traumatic brain injury includes comprehensive history, polysomnography, actigraphy, and multiple sleep latency test.
	• Treatment is disorder specific and may include the use of medications, continuous positive airway pressure, light therapy, and behavioral modifications.

Historical note and terminology

Traumatic brain injury is a significant cause of disability and death in the United States and worldwide. It is most frequently classified as mild, moderate, or severe using the Glasgow Coma Scale (mild = 13 to 15; moderate = 9 to 12; severe = less than or equal to 8 out of 15) (64). Although there is paucity of literature on relationship between head trauma and sleep disturbances, there has been emerging evidence recognizing the association between sleep disturbances in brain injury and poor cognitive, behavioral, and psychiatric outcomes (44). Sleep disturbances after traumatic brain injury are thought to occur in 30% to 70% of patients and often impair the resumption of the individuals normal activities (35).

Clinical manifestations

Presentation and course

Head trauma frequently leads to the appearance of wide variety of sleep disturbances, more frequently in those suffering mild head injury (31). Various sleep related disturbances encountered are listed above in Table 1. In all instances, the altered sleep pattern deviates greatly from the pre-head trauma sleep patterns.

One of the more common problems following head injury involves difficulties initiating and maintaining sleep, either with or without subjective daytime sleepiness. A meta-analysis of 21 studies comprising of 1706 traumatic brain injury survivors reported insomnia symptoms (50%), decreased sleep maintenance and sleep efficiency (49% to 50%), delayed sleep onset (36%), early morning awakenings (38%), and nightmares (27%) (35). In some cases, the insomnia is a manifestation of a circadian rhythm sleep disorder, typically delayed sleep-wake phase disorder or irregular sleep-wake rhythm disorder (03).

Among male military personnel, multiple traumatic brain injuries were found to increase the risk of insomnia (09; 36). Nightmares commonly interrupt sleep in veterans with posttraumatic stress disorder (PTSD) and mild traumatic brain injury (50; 04). Veterans of the United States campaigns in Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) complaining of insomnia associated with mild traumatic brain injury and PSTD were found to report subjective sleepiness compared to veterans with insomnia due to PTSD alone (60).

Patients with traumatic brain injury have demonstrated increased prolonged sleep latency, sleep fragmentation, increased wake time after sleep onset, reduced total sleep time and efficiency, reduced REM latency, and decrease in total REM sleep (36; 62). According to a study, younger age, preserved memory, and comorbid depression were predictors of good response to cognitive behavioral therapy for insomnia (CBT-I) (42).

Hypersomnia developing after a head injury can be very disabling for the patient, with significant impact on quality of life. Although it can improve with time to some extent, persists in many cases (16; 62). Features of both hypersomnia and narcolepsy with or without cataplexy can emerge in posttraumatic patients (59). In cases where posttraumatic hypersomnia is present for at least three months (without any other cause such as another sleep or psychiatric disorder and/or medication), multiple sleep latency testing (MSLT) can demonstrate a mean sleep latency of eight minutes or less. The International Classification of Sleep Disorders, third edition (ICSD-3), published by the American Academy of Sleep Medicine classifies this as hypersomnia due to a medical disorder (01). If hypersomnia after a head injury occurs in association with two or more sleep-onset REM periods during MSLT testing, the diagnosis is narcolepsy type 1 or 2 due to a medical condition. Head trauma has also been reported to precipitate cases of Kleine-Levin syndrome, which is a rare disorder consisting of periodic recurrent hypersomnia with cognitive or behavioral disturbances, hypersexuality, and/or compulsive eating during an occurrence with complete resolution in between episodes (02).

A number of other sleep disorders have also been found in patients with head trauma. Masel and colleagues examined a series of 71 brain injury patients in a residential treatment program, all without a prior history of hypersomnia or sleep disturbance (34). Among 33 (46.5%) hypersomnolent patients, four had obstructive sleep apnea, seven had periodic limb movement disorder, and one had narcolepsy (in addition to periodic limb movement disorder). The remaining 21 patients were given a diagnosis of posttraumatic hypersomnia.

In an extensive series of 184 traumatic brain injury patients, Guilleminault and colleagues found that 32% of the patients were discovered to suffer from sleep-disordered breathing (primarily obstructive sleep apnea) (22). The authors noted that all 16 whiplash patients were diagnosed with sleep-disordered breathing. Traumatic brain injury patients with obstructive sleep apnea have greater degree of neurocognitive and attention deficits (63).

Castriotta and colleagues prospectively studied 87 adults at least three months after traumatic brain injury. Polysomnography and multiple sleep latency tests were administered to all subjects. Forty-six percent of the patients had abnormal sleep studies. The authors diagnosed 23% with obstructive sleep apnea, 11% with posttraumatic hypersomnia, 7% with periodic limb movements in sleep, and 6% with narcolepsy (12).

Head trauma occasionally precipitates parasomnias, NREM (such as sleepwalking), and REM sleep behavior disorder (59). Lesion of subcoeruleus nucleus of brainstem can cause increase in muscle tone during REM with dream enactment behavior (37).

Fatigue is another complaint associated with traumatic brain injury with untoward consequences on quality of life. In a study of 119 patients at least one year after traumatic brain injury, up to 53% reported fatigue, which was more prevalent in women or those with symptoms of depression, pain, or sleep disturbance (17). Studies have shown consequential improvement in mood, both depression and anxiety, upon treating sleep and fatigue in traumatic brain injury patients (42). According to one study, cognitive-behavioral treatment for insomnia (CBTI) was effective in improving fatigue in 55% of patients.

Psychiatric disorders like anxiety and depression add further layers of complexity to the posttraumatic sleep disturbances. Patients with mild traumatic brain injury and sleep complaints were more likely to report feeling depressed at 10 days and six weeks after their injury (13). In a large study of military personnel, a positive screening for traumatic brain injury and sleep problems were found to be early indicators of risk for developing PTSD, or depression, or both (30). New-onset anxiety after head injury is a significant predictor of sleep disturbance, though the cause-effect relationship is unclear (48).

Prognosis and complications

There are few longitudinal studies of patients with posttraumatic sleep disorders. The general clinical impression is that once stabilized, sleep disturbance related to organic brain damage shows little further change, other than a response to treatment (TBI). A prospective cohort study examined sleepiness in 514 traumatic brain injury patients one month after the injury, and then at one year. At one month, 55% endorsed at least one item on a four-item sleepiness questionnaire. At one year, only 27% endorsed one or more of the sleepiness items (61). Another prospective study of 51 patients with traumatic brain injury showed that at three years post-injury, 67% of the patients continued to complain of sleep-wake disturbances, especially fatigue and hypersomnia (27). Disturbed nocturnal sleep may be a marker of more severe injury in patients with closed head injury (32). Improved sleep efficiency is correlated with resolution of posttraumatic amnesia (33). One study also indicated that sustaining a traumatic brain injury in childhood can also increase risk of sleep wake disorders in young adulthood, especially after moderate traumatic brain injury (07). The same investigators also demonstrated that in moderate traumatic brain injury survivors, poor subjective sleep was associated with poor sleep, fatigue, and poor perception of general health (08).

In persons with traumatic brain injury, the presence of obstructive sleep apnea is associated with further impairment of sustained attention and memory than in patients with comparable severity traumatic brain injury without obstructive sleep apnea (63; 20). Traumatic brain injury patients with excessive daytime sleepiness have slower reaction times and poorer performance on the Psychomotor Vigilance Test than nonsleepy patients (12).

Clinical vignette

Case 1. BJ was a 55-year-old man who had experienced sleepiness since a motor vehicle accident five years prior to presentation. An electroencephalogram one year after his accident showed evidence of moderate diffuse cerebral dysfunction. Since the injury, he had experienced a number of neuropsychiatric symptoms, including depression, sleepiness, mood lability, headaches, memory impairment, executive dysfunction, and impulsivity. A polysomnogram performed three years prior to presentation showed mild obstructive sleep apnea with an apnea-hypopnea index of 14. Treatment for obstructive sleep apnea was not initiated due to lack of follow-up at the sleep clinic. His neuropsychiatrist initiated modafinil due to sleepiness. His medications included valproic acid, escitalopram, fentanyl, galantamine, and modafinil 100 mg per day. He was later referred to the sleep clinic for reevaluation.

Modafinil partially improved his sleepiness, but higher doses precipitated manic episode in which he could not sleep for several days. His wife reported that he used to snore loudly, but this had subsided recently. In addition to chronic sleepiness, BJ also reported sudden sleep attacks. History of cataplexy was not elicited. A repeat polysomnography did not demonstrate significant sleep apnea, and an MSLT was recommended, but he did not follow through. He was later lost to follow-up.

Case 2. RW suffered a closed head injury at work in which an object struck his right parietotemporal region. He developed symptoms of sleep apnea, including snoring, sleepiness, and witnessed apneas, about one month after the accident. He denied sleep apnea symptoms prior to the injury. Examination was remarkable for obesity, an enlarged neck circumference, a thickened tongue base, and a long soft palate.

Polysomnography demonstrated an apnea-hypopnea index of 132, consisting mainly of obstructive apneas and hypopneas, but also included a moderate number of central and mixed apneas, with a brief period of periodic respiratory pattern in the early portion of the study. He was given a diagnosis of severe sleep apnea, predominantly obstructive but with a central component.

Subsequent continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) titrations demonstrated that these modalities were ineffective for treating his sleep apnea. BiPAP therapy in the spontaneous timed mode (BiPAP-ST®) prevented most respiratory events, but sleep fragmentation and significant arousals remained. RW was prescribed BiPAP-ST at 20/12 cm H2O with a backup rate of 12. This improved his sleepiness, but he continued to have frequent nocturnal awakenings despite use of eszopiclone. An adaptive servo ventilation titration was recommended to assess if respiratory disturbances and sleep fragmentation could improve.

These two cases illustrate the challenges of treating sleepiness resulting from head injuries.

Biological basis

Etiology and pathogenesis

Closed head injury is most commonly caused by falls (28%), motor vehicle accidents (20%), impact from an object (19%), and assaults (11%) (28). The mechanism of injury is less important than the site. Past studies failed to show correlation between severity of traumatic brain injury and resultant sleep disturbances, but new emerging evidence demonstrates strong association of intracranial hemorrhage and low Glasgow coma scales with increased sleep (24).

Depending on the impact intensity, direction, and duration of the acceleration/deceleration, different types and extent of damage can occur. Closed head injury is known to lead to "shearing" forces along the direction of main fiber pathways, causing microhemorrhages in these areas.

Various pathophysiological mechanisms have been postulated for different manifestation of posttraumatic sleep disturbances (52). Damage to areas involved in maintenance of wakefulness, including brainstem reticular formation and posterior hypothalamus, can lead to emergence of hypersomnia. High cervical cord lesions have also been known to cause sleepiness and sleep attacks (23).

Most patients with moderate to severe traumatic brain injury have low or intermediate hypocretin-1 levels in the acute phase of injury, which tend to improve by six months (05). Postmortem analysis of traumatic brain injury patients have revealed reduction in wake promoting hypocretinergic and histaminergic neurons (58).

Countercoup brain lesions following head injury most frequently occur at the base of the skull and may result in organic posttraumatic insomnia. They occur in areas of bony irregularities (especially the sphenoid ridges), with consequent damage to the inferior frontal and anterior temporal regions, including the basal forebrain, an area involved in sleep initiation. Sleep-wake disturbances after mild traumatic brain injury are associated with a longer tentorial length and flatter tentorial angle (the angle formed between the tentorium and a line through the foramen magnum) compared to patients with mild traumatic brain injury without sleep-wake disturbances. The authors postulated that direct impact involving the tentorium and pineal gland leads to pineal gland injury in mild trauma, which results in disruption of melatonin homeostasis and sleep-wake disturbances (66). Studies on mice with traumatic brain injury, have shown low concentration of melatonin-1 (MT1) and melatonin-2 (MT2) receptors (43).

Closed head injury may involve the nucleus suprachiasmaticus or its output. This can lead to disturbance of the circadian rhythm and, subsequently, a combination of hypersomnia and insomnia. A complete reversal of the circadian rhythmicity has also been reported (06). In one case, a 20-year-old man suffered mild to moderate traumatic brain injury and penetrating eye injury after an improvised explosive device blast (10). He developed a free-running type of circadian rhythm and was successfully treated with evening melatonin. Disruption of retinohypothalamic tract, which regulates circadian pacemaker, can lead to sleep wake rhythm disturbances (19). One study revealed 42% reduction in melatonin secretion and delay in dim light melatonin onset by 1.5 hours in traumatic brain injury patients as compared to controls (19).

Diagnostic workup

A detailed account of a patients sleep history obtained with assistance of caregiver is crucial in order to (1) document the association of the sleep disorder with the trauma, (2) rule out any preexisting sleep disorder, (3) assess the evolution of course after the head injury, and (4) and measure the impact of interventions. Physical examination greatly assists in clinical decision making.

Out of numerous questionnaires, 16 have been studied in the traumatic brain injury population (39). Although there are inherent limitations in obtaining subjective data, Epworth Sleepiness Score (ESS) and Pittsburgh Sleep Quality Index (PSQI) have been validated against objective parameters in traumatic brain injury patients (18; 34). In terms of the latter, global PSQI score of 8 or better delineated the patients with clinically significant insomnia in traumatic brain injury (18). Fatigue severity score (FSS) can be used to assess and monitor changes in fatigue after CBT-I intervention (42). Some other questionnaires employed in this population include Morning-Eveningness Questionnaire (MEQ), Insomnia Severity Index (ISI), and the Swiss Narcolepsy Scale (SNS) (39). A sleep and concussion questionnaire (SCQ) has been proposed for mild TBI cases, which demonstrated convergent validity with objective parameters obtained through polysomnography and other self-reported measures such as insomnia severity index (ISI) and Epworth Sleepiness Score (ESS) (57).

Polysomnography should be done to determine the nature of the posttraumatic nocturnal sleep disturbance, as well as rule out coexistent sleep pathologies, such as sleep apnea and periodic movements in sleep.

Posttraumatic sleep disturbance polysomnogram

Slow respiratory rate (five to six per minute) during NREM sleep in a 12-year-old child with a traumatic midbrain injury. (Contributed by Dr. Michael Aldrich.)

Cases with posttraumatic hypersomnia have generally shown an increase in nightly sleep duration with or without changes in other sleep measures (21; 37). In patients with posttraumatic insomnia, sleep architecture has shown long sleep latencies, low sleep efficiency, a decrease in nightly sleep duration, and increased stage 1 sleep (45; 36; 62). Compared to controls, patients with moderate to severe traumatic brain injury had increased slow wave sleep, a reduction in REM sleep, and more frequent nocturnal awakenings (19).

Continuous polysomnography has confirmed an increase in total sleep per 24 hours in some patients with posttraumatic hypersomnia (21). From a historical perspective, it is of interest that polysomnography during the comatose period has prognostic value for the development of full recovery without posttraumatic sleep disturbance. Normal amounts of sleep spindles, K-complexes, and normal non-NREM and REM cyclicity within sleep are favorable prognostic signs (29). Young age, relatively better cognitive status, and higher depression scores predict good clinical response to CBT-I (42). Actigraphy may be a helpful adjunct to a sleep diary in those who have suffered a brain injury (54).

If daytime sleepiness is a major complaint, a multiple sleep latency test following polysomnography may be helpful to determine if a central hypersomnia is present. In posttraumatic hypersomnia with daytime sleepiness, sleep latency may be markedly shortened (21). On the other hand, patients with posttraumatic insomnia exhibit prolonged sleep latencies on multiple sleep latency tests, as well as in nocturnal sleep studies. As already mentioned, the presence of sleep-disordered breathing and sleep-onset REM periods does not eliminate the possibility that the head trauma was the precipitating factor in the development of the sleep disorder. Because a driving accident also may be due to prior existing sleepiness, a thorough inquiry is needed to appropriately compensate victims of secondary sleep disorders, even in the presence of preexisting risk factors. The medical workup should include assessment of the activity of the individual prior to the accident. This assessment should also include: (1) interviews of bed partners and coworkers; (2) investigation of employer records, prior health reports, driving records; and (3) employment history, including absenteeism.

Management

The approach to management should involve focused intervention, based on the specific type of sleep disturbance experienced by the individual.

Insomnia

Non-pharmacological intervention. Although pharmacological treatment of insomnia has been challenging, cognitive behavioral therapy for insomnia (CBTI) has demonstrated promising results (42). Behavioral techniques should be utilized for all insomnia patients. Psychological therapies are beneficial and include stimulus control, therapy, relaxation training, and cognitive behavioral therapy. Other modalities likely used with these are sleep restriction, therapy, biofeedback, and sleep hygiene education (40; 42). These therapies can improve nocturnal sleep quality as well as reduce daytime fatigue in those with insomnia related to traumatic brain injury (46). In addition, acupuncture may also be a viable treatment in improving sleep quality following traumatic brain injury (67). Daily morning blue light therapy has also demonstrated increase in total sleep duration (47).

Pharmacological Intervention. There are lack of scientific data regarding use of sedative agents in this specific population. Current guidelines recommend against the use of benzodiazepines due to adverse effects on cognition, risk of dependency, and/or abuse. The nonbenzodiazepine receptor agonists are extensively used, including zolpidem, the longer-acting eszopiclone, and the shorter-acting zaleplon. Although these medications are often helpful with initiating and/or maintaining sleep, they are associated with some concerning side effects, including complex sleep-related behaviors (ie, sleepwalking and sleep-related eating disorder). One paper reported increased risk of dementia with use of hypnotics in traumatic brain injury patients (14). Additionally, many sedating antidepressants are used for insomnia, especially when comorbid depression exists. These medications include trazodone, mirtazapine, and doxepin. These are also associated with many side effects and should be used with caution in elderly patients. Suvorexant is a newer agent approved for the treatment of insomnia, which acts by blocking the binding of wake-promoting neuropeptides (orexin A and B) to receptors (OX1R and OX2R) to suppress the wake drive. This medication should be used with care as it can lead to impaired motor coordination, complex sleep-related behaviors, mood/behavioral/cognitive changes, sleep paralysis, and/or cataplexy-like symptoms. Furthermore, patients are often treated with many other medications off-label (ie, gabapentin, quetiapine, or olanzapine) due to well-known side effect of sleepiness. Over-the-counter medications are often used to aid sleep, such as diphenhydramine, doxylamine, and hydroxyzine (all first-generation antihistamines). Melatonin and various herbal supplements are also frequently utilized, including valerian, gamma-aminobutyric, 5-L-5-hydroxytryptophan, kava, and many others. When using any of these medications, the prescriber should caution the patient not to drive (or do any other activity that could be of danger to self or others) after taking the medication. The patient should not use these medications with alcohol and use restraint when taking these with other sedating medications.

Selective serotonin reuptake inhibitors for depression or anxiety should be taken in the morning because they can induce insomnia when taken at bedtime. Lastly, tricyclic antidepressants are frequently used to treat chronic pain issues and may also help with insomnia due to their sedating effects.

Hypersomnia

Non-pharmacological intervention. Patients with hypersomnolence should be educated regarding strategic napping, caffeine, and driving precautions. Blue light therapy has shown promise in improving daytime sleepiness, fatigue, and quality of life with recovery in post-concussion symptoms and depression severity. Studies have shown improvement in Epworth Sleepiness Score, Beck Depression Inventory, and functional outcome of sleep questionnaire scores (47; 55).

Pharmacological Intervention. Patients with posttraumatic narcolepsy or hypersomnia may benefit from the use of an alerting agent. Modafinil may be the medication of first intention because it has fewer side effects than other stimulants. The dosage is usually 200 to 400 mg, administered in two divided doses in the morning and at lunchtime. A prospective, double-blind, randomized, placebo-controlled trial found that modafinil (100 to 200 mg given each morning) significantly improved sleepiness measured by the Epworth Sleepiness Scale and the maintenance of wakefulness test. Modafinil was not found to be effective for fatigue (26). However, another study found modafinil to be of limited effectiveness for sleepiness associated with traumatic brain injury (25). Armodafinil, the R-enantiomer of modafinil, is dosed only once per day (38). Methylphenidate and amphetamines are also used in those with narcolepsy (or hypersomnia) related to head injury. Patients with severe head trauma who complain of intellectual slowness may benefit more from amphetamine-based medications because these have a general activating effect that is not solely devoted to sleepiness. When cataplexy is present in narcolepsy, sodium oxybate may be prescribed because it is effective not only for the treatment of sleepiness, but also can reduce the frequency of cataplexy and consolidates sleep. A tricyclic antidepressant, selective serotonin reuptake inhibitor, or venlafaxine can also be prescribed to reduce disabling cataplexy, if present (40).

Restless leg syndrome

Management of restless leg syndrome associated with traumatic brain injury is the same as restless leg syndrome in general population. The dopamine agonists (ie, ropinirole or pramipexole) or alpha2 Delta ligands (gabapentin, pregabalin, and gabapentin enacarbil) are commonly used to treat this disorder. Levodopa has been proven effective but due to the risk of augmentation, it is utilized less frequently. Narcotics and benzodiazepines are only reserved for more significant cases not responsive to other medications. Importantly, iron storage levels should be investigated in these patients to ensure a ferritin level greater than 75 ng/mL. In the event of low ferritin, iron supplementation is the treatment of choice.

Sleep related disordered breathing

Cases of sleep apnea resulting from a head injury are treated in the usual manner with various modes of positive airway pressure, continuous (CPAP), or bilevel (bilevel PAP) therapy. Sometimes the spontaneous/timed mode of BiPAP therapy or adaptive-servo ventilation is necessary for central sleep apnea or when both obstructive and central sleep apnea are present.

Other treatments alternatives for obstructive sleep apnea include mandibular advancement devices. These are used when mild or moderate obstructive sleep apnea is present and have a success rate around 50%. They are less effective for severe obstructive sleep apnea and in those with a higher body mass index.

Surgical procedures are considered at times, especially in those with severe obstructive sleep apnea in those who have difficulty tolerating positive airway pressure. Surgical procedures can include tonsillectomy, septoplasty, turbinate reduction, uvulopalatopharyngoplasty, genioglossus advancement, and hyoid myotomy and/or maxillomandibular advancement. Tracheostomy is rarely used for obstructive sleep apnea; it is reserved for life-threatening cases. Weight reduction surgeries are another surgical consideration in morbidly obese patients with obstructive sleep apnea. In addition, a surgically implanted hypoglossal nerve stimulation contraption is used to treat obstructive sleep apnea (53).

Finally, conservative treatments for obstructive sleep apnea include weight loss, avoiding the supine position during sleep, and maintaining nasal patency with the use of saline spray or prescribed nasal steroid spray, if needed. One should also avoid alcohol and medications that may reduce muscle tone or influence the respiratory drive (ie, narcotics and benzodiazepines) prior to bedtime (40).

When approaching a patient with a posttraumatic brain injury sleep disorder, the clinician must also attend to underlying pain, depression, and anxiety, as these issues can greatly impact sleep. Therapy for posttraumatic stress disorder could also be helpful in ameliorating the sleep disturbances. Those self-medicating posttraumatic brain injury symptoms with alcohol risk sleep disruption, nightmares, reduction in REM sleep, and worsening sleep apnea; thus, counselling regarding sleep practices is vitally important.

Outcomes

Unfortunately, there is a dearth of clinical data regarding treatment of sleep disorders associated with traumatic brain injury. Although targeted management of sleep disorders might improve objective measures in few cases, clinical outcomes have remained poor in terms of subjective sleep and neuropsychological function (11; 26; 37). Encouragingly, an Australian study demonstrated significant clinical improvement in insomniac patients in sleep measures with mean PSQI <5 with cognitive behavioral therapy for insomnia (CBT-I). Seventy percent of the patients showed drastic improvement in sleep scores, and 55% showed positive trend in fatigue measurement (42). Another observational study focusing on CBT-I treatment of insomnia demonstrated decrease in C-reactive protein, an inflammatory marker in patients who had improvement in sleep (04). Contradictory to these, in a group of 57 patients with traumatic brain injury, Castriotta and colleagues polysomnographically documented sleep disorders in 22 subjects (39%) where treatment did not lead to significant changes in quality of life, mood, or cognitive performance. Treatment of obstructive sleep apnea (13 subjects, 23%) with CPAP did not lead to improvement in sleepiness, as measured by the Epworth Sleepiness Scale and MSLT. According to a few other studies, modafinil and armodafinil improve subjective and objective sleepiness but did not have much improvement in functional outcome due to fatigue, which underscores the multifaceted nature of the posttraumatic sleep disturbances (26; 38). Studies regarding use of daily blue light have shown substantial improvement in not only subjective scores of Epworth Sleepiness Score, Beck Depression Inventory, and post-concussion symptom questionnaire, but also normalized wake after sleep onset and greater total sleep time. These findings led to improvement of functional outcome of sleep questionnaire scores (47).

References

01: American Academy of Sleep Medicine. International Classification of Sleep Disorders. Diagnostic and coding manual, 3rd edition. American Academy of Sleep Medicine, 2014.**
02: Arnulf I, Zeitzer JM, File J, Farber N, Mignot E. Kleine-Levin syndrome: a systematic review of 186 cases in the literature. Brain 2005;128:2763-76. PMID 16230322
03: Ayalon L, Borodkin K, Dishon L, Kanety H, Dagan Y. Circadian rhythm sleep disorders following mild traumatic brain injury. Neurology 2007;68(14):1136-40. PMID 17404196
04: Barr T, Livingston W, Guardado P, Baxter T, Mysliwiec V, Gill J. Chapter 8 military personnel with traumatic brain injuries and insomnia have reductions in PTSD and imporved perceived health following sleep restoration: a relationship moderated by inflammation. Annu Rev Nurs Res 2015;33:249-66. PMID 25946388
05: Baumann CR, Werth E, Stocker R, Ludwig S, Bassetti CL. Sleep-wake disturbances 6 months after traumatic brain injury: a prospective study. Brain 2007;130(Pt 7):1873-83. PMID 17584779
06: Billiard M, Negri C, Baldy-Moulignier M, Roquefeuille B, Passouant P. Organisation du sommeil chz les sujets atteints dinconscience post-traumatique chronique. Rev EEG Neurophysiol 1979;9:149-52. PMID 231288
07: Botchway EN, Godfrey C, Anderson V, Nicholas CL, Catroppa C. Outcomes of subjective sleep-wake disturbances twenty years after traumatic brain injury in childhood. J Neurotrauma 2019;36(5):669-78. PMID 30180783
08: Botchway EN, Godfrey C, Ryan NP, et al. Sleep disturbances in young adults with childhood traumatic brain injury: relationship with fatigue, depression, and quality of life. Brain Inj 2020;34(12):1579-89. PMID 33054410
09: Bryan CJ. Repetitive traumatic brain injury (or concussion) increases severity of sleep disturbance among deployed military personnel. Sleep 2013;36(6):941-6. PMID 23729938
10: Carter KA, Lettieri CJ, Pena JM. An unusual cause of insomnia following IED-induced traumatic brain injury. J Clin Sleep Med 2010;6(2):205-6. PMID 20411701
11: Castriotta RJ, Atanasov S, Wilde MC, Masel BE, Lai JM, Kuna ST. Treatment of sleep disorders after traumatic brain injury. J Clin Sleep Med 2009;5(2):137-44. PMID 19968047
12: Castriotta RJ, Wilde MC, Lai JM, Atanasov S, Masel BE, Kuna ST. Prevalence and consequences of sleep disorders in traumatic brain injury. J Clin Sleep Med 2007;3(4):349-56. PMID 17694722
13: Chaput G, Giguère JF, Chauny JM, Denis R, Lavigne G. Relationship among subjective sleep complaints, headaches, and mood alterations following a mild traumatic brain injury. Sleep Med 2009;10:713-6. PMID 19147402
14: Chiu HY, Lin EY, Wei L, et al. Hypnotics use but not insomnia increased the risk of dementia in traumatic brain injury patients. European Neuropsychopharmacol 2015;25(12):2271-7. PMID 26454682
15: Crichton T, Singh R, Abosi-Appeadu K, Dennis G. Excessive daytime sleepiness after traumatic brain injury. Brain Inj 2020;34(11):1525-31. PMID 32835526
16: Collen J, Orr N, Lettieri CJ, Carter K, Holley AB. Sleep disturbances among soldiers with combat-related traumatic brain injury. Chest 2012;142(3):622-30. PMID 22459784
17: Englander J, Bushnik T, Oggins J, Katznelson L. Fatigue after traumatic brain injury: association with neuroendocrine, sleep, depression and other factors. Brain Injury 2010;24:1379-88. PMID 20961172
18: Fictenberg NL, Putnam SH, Mann NR, Zafonte RD, Milliard AE. Insomnia screening in postacute traumatic brain injury: utility and validity of the Pittsburgh Sleep Quality Index. Am J Phys Med Rehabil 2001;80(5):339-45. PMID 11327555
19: Grima N, Ponsford J, Rajaratnam SM, Mansfield D, Pase MP. Sleep disturbances in traumatic brain injury: a meta-analysis. J Clin Sleep Med 2016;12(3):419-28. ** PMID 26564384
20: Grima N, Rajaratnam S, Mansfield D, Sletten TL, Spitz G, Ponsford JL. Efficacy of melatonin for sleep disturbance following traumatic brain injury: a randomised controlled trial. BMC Med 2018;16(1):8. PMID 29347988
21: Guilleminault C, Faull KF, Miles L, van den Hoed J. Posttraumatic excessive daytime sleepiness: a review of 20 patients. Neurology 1983;33:1584-9. PMID 6685831
22: Guilleminault C, Chervin R, Palombini L, Powell N. Radiofrequency (pacing and thermic effects) in the treatment of sleep-disordered breathing. Sleep 2000;23 Suppl 4:S182-6. PMID 10893098
23: Hall CW, Danoff D. Sleep attacks: apparent relationship to atlantoaxial dislocation. Arch Neurol 1975;32:58-9. PMID 1115663
24: Imbach LL, Büchele F, Valko PO, et al. Sleep-wake disorders persist 18 months after traumatic brain injury but remain underrecognized. Neurology 2016;86(21):1945-9.** PMID 27164676
25: Jha A, Weintraub A, Allshouse A, et al. A randomized trial of modafinil for the treatment of fatigue and excessive daytime sleepiness in individuals with chronic traumatic brain injury. J Head Trauma Rehabil 2008;23(1):52-63. PMID 18219235
26: Kaiser PR, Valko PO, Werth E, et al. Modafinil ameliorates excessive daytime sleepiness after traumatic brain injury. Neurology 2010;75:1780-5. PMID 21079179
27: Kempf J, Werth E, Kaiser PR, Bassetti CL, Baumann CR. Sleep-wake disturbances 3 years after traumatic brain injury. J Neurol Neurosurg Psychiatry 2010;81:1402-5. PMID 20884672
28: Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control 2006.
29: Lessard CS, Sances A, Larson SJ. Period analysis of EEG signals during sleep and posttraumatic coma. Aerospace Med 1974;45:664-8.
30: Macera CA, Aralis HJ, Rauh MJ, MacGregor AJ. Do sleep problems mediate the relationship between traumatic brain injury and the development of mental health symptoms after deployment. Sleep 2013;36(1):83-90. PMID 23288974
31: Mahmood O, Rapport LJ, Hanks RA, Fichtenberg NL. Neuropsychological performance and sleep disturbance following traumatic brain injury. J Head Trauma Rehabil 2004;19(5):378-90. PMID 15597029
32: Makley MJ, English JB, Drubach DA, Kreuz AJ, Celnik PA, Tarwater PM. Prevalence of sleep disturbance in closed head injury patients in a rehabilitation unit. Neurorehabil Neural Repair 2008;22(4):341-7. PMID 18663247
33: Makley MJ, Johnson-Greene L, Tarwater PM, et al. Return of memory and sleep efficiency following moderate to severe closed head injury. Neurorehabil Neural Repair 2009;23(4):320-6. PMID 19171947
34: Masel BE, Scheibel RS, Kimbark T, Kuna ST. Excessive daytime sleepiness in adults with brain injuries. Arch Phys Med Rehabil 2001;82(11):1526-32. PMID 11689971
35: Mathias JL, Alvaro PK. Prevalence of sleep disturbances, disorders, and problems following traumatic brain injury: a meta-analysis. Sleep Med 2012;13(7):898-905. PMID 22705246
36: Matthews EE, Signoracci G, Stearns-Yoder K, Brenner LA. A qualitative study of sleep-wake disturbance among veterans with post-acute moderate to severe traumatic brain injury. J Head Trauma Rehabil 2016;31(2):126-35. PMID 26959666
37: Mazwi NL, Fusco H, Zafonte R. Sleep in traumatic brain injury. Handb Clin Neurol 2015;128:553-66.** PMID 25701907
38: Menn SJ, Yang R, Lankford A. Armodafinil for the treatment of excessive sleepiness associated with mild or moderate closed traumatic brain injury: a 12-week, randomized double-blind study followed by a 12-month open-label extension. J Clin Sleep Med 2014;10(11):1181-91. PMID 25325609
39: Mollayeva T, Colantonio A, Mollayeva S, Shapiro C. Screening for sleep dysfunction after traumatic brain injury. Sleep Med 2013;14(12):1235-46. PMID 24211035
40: Morgenthaler T, Kramer M, Alessi C, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An American Academy of Sleep Medicine report. Sleep 2006;29(11):1415-9. PMID 17162987
41: Nakase-Richardson R, Sherer M, Barnett SD, et al. Prospective evaluation of the nature, course, and impact of acute sleep abnormality after traumatic brain injury: a pilot randomized controlled trial. Arch Phys Med Rehabil 2013;94(5):87582. PMID 23296143
42: Nguyen S, McKay A, Wong D, et al. Cognitive behavior therapy to treat sleep disturbance and fatigue after traumatic brain injury: a pilot randomized controlled trial. Arch Phys Med Rehabil 2017;98(8):1508-17. PMID 28400181
43: Osier ND, Pham L, Pugh BJ, et al. Brain injury results in lower levels of melatonin receptors subtypes MT1 and MT2. Neurosci Lett 2017;650:18-24. PMID 28377323
44: Ouellet MC, Beaulieu-Bonneau S, Morin CM. Sleep-wake disturbances after traumatic brain injury. Lancet Neurol 2015;14(7):746-57. PMID 26067127
45: Ouellet MC, Morin CM. Subjective and objective measures of insomnia in the context of traumatic brain injury: a preliminary study. Sleep Med 2006;7(6):486-97. PMID 16934524
46: Ouellet MC, Morin CM. Efficacy of cognitive-behavioral therapy for insomnia associated with traumatic brain injury: a single-case experimental design. Arch Phys Med Rehabil 2007;88(12):1581-92. PMID 18047872
47: Raikes AC, Dailey NS, Shane BR, Forbeck B, Alkozei A, Killgore WDS. Daily morning blue light therapy improves daytime sleepiness, sleep quality, and quality of life following a mild traumatic brain injury. J Head Trauma Rehabil 2020;35(5):E405-21. PMID 32472836
48: Rao V, Spiro J, Vaishnavi S, et al. Prevalence and types of sleep disturbances acutely after traumatic brain injury. Brain Inj 2008;22(5):381-6. PMID 18415718
49: Rodrigues RN, Silva AA. Excessive daytime sleepiness after traumatic brain injury: association with periodic limb movements and REM behavior disorder: case report. Arquivos de Neuro-Psiquiatria 2002;60:656-60. PMID 12244410
50: Ruff RL, Ruff SS, Wang XF. Improving sleep: initial headache treatment in OIF/OEF veterans with blast-induced mild traumatic brain injury. J Rehabil Res Dev 2009;46(9):1071-84. PMID 20437313
51: Rutland-Brown W, Langlois JA, Thomas KE, Xi LY. Incidence of traumatic brain injury in the United States, 2003. J Head Trauma Rehabil 2006;21(6):544-8. PMID 17122685
52: Sandsmark DK, Elliot JE, Lim MM. Sleep-wake disturbances after traumatic brain injury: synthesis of human and animal studies. Sleep 2017;40(5). PMID 28329120
53: Schwartz AR. Hypoglossal nerve stimulation-optimizing its therapeutic potential in obstructive sleep apnea. J Neurol Sci 2014;346(1-2):1-3. PMID 25190292
54: Sinclair KL, Ponsford JL, Taffe J, Lockley SW, Rajaratnam SM. Randomized controlled trial of light therapy for fatigue following traumatic brain injury. Neurorehabil Neural Repair 2014b;28(4):303-13. PMID 24213962
55: Srisurapanont K, Samakarn Y, Kamklong B, Siratrairat P, et al. Blue-wavelength light therapy for post-traumatic brain injury sleepiness, sleep disturbance, depression, and fatigue: A systematic review and network meta-analysis. PLoS One 2021;16(2):e0246172.** PMID 33539446
56: Theodorou AA, Rice SA. Is the silent epidemic keeping patients awake. J Clin Sleep Med 2007;3(4):347-8. PMID 17694721
57: Toccalino D, Wiseman-Hakes C, Zalai DM. Preliminary validation of the sleep and concussion questionnaire as an outcome measure for sleep following brain injury. Brain Inj 2021;35(7):743-50.** PMID 33843391
58: Valko PO, Gavrilov YV, Yamamoto M, et al. Damage to histaminergic tuberomammillary neurons and other hypothalamic neurons with traumatic brain injury. Ann Neurol 2015;77(1):177-82.** PMID 25363332
59: Verma A, Anand V, Verma NP. Sleep disorders in chronic traumatic brain injury. J Clin Sleep Med 2007;3(4):357-62. PMID 17694723
60: Wallace DM, Shafazand S, Ramos AR, et al. Insomnia characteristics and clinical correlates in Operation Enduring Freedom/Operation Iraqi Freedom veterans with post-traumatic stress disorder and mild traumatic brain injury: an exploratory study. Sleep Med 2011;12(9):850-9. PMID 21925943
61: Watson NF, Dikmen S, Machamer J, Doherty M, Temkin N. Hypersomnia following traumatic brain injury. J Clin Sleep Med 2007;3(4):363-8. PMID 17694724
62: Wickwire EM, Williams SG, Roth T, et al. Sleep, sleep disorders, and mild traumatic brain injury. What we know and what we need to know: findings from a national working group. Neurotherapeutics 2016;13(2):403-17.** PMID 27002812
63: Wilde MC, Castriotta RJ, Lai JM, Atanasov S, Masel BE, Kuna ST. Cognitive impairment in patients with traumatic brain injury and obstructive sleep apnea. Arch Phys Med Rehabil 2007;88(10):1284-8. PMID 17908570
64: Winston SR. Preliminary communication: EMT and the Glasgow [correction of Glascow] Coma Scale. J Iowa Med Soc 1979;69(10):393, 398. PMID 490000
65: Wolf GK, Mauntel GJ, Kretzmer T, et al. Comorbid posttraumatic stress disorder and traumatic brain injury: generalization of prolonged-exposure PTSD treatment outcomes to postconcussive symptoms, cognition, and self-efficacy in veterans and active duty service members. J Head Trauma Rehabil 2018;33(2):E53-63. PMID 28926486
66: Yaeger K, Alhilali L, Fakhran S. Evaluation of tentorial length and angle in sleep-wake disturbances after mild traumatic brain injury. AJR Am J Roentgenol 2014;202(3):614-8. PMID 24555599
67: Zollman FS, Larson EB, Wasek-Throm LK, Cyborski CM, Bode RK. Acupuncture for treatment of insomnia in patients with traumatic brain injury: a pilot intervention. J Head Trauma Rehabil 2012;27(2):135-42. PMID 21386714

Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Author

Muna Irfan MD

Dr. Irfan of Minnesota Regional Sleep Disorders Center has no relevant financial relationships to disclose.
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Editor

Michael J Howell MD

Dr. Howell of the University of Minnesota has no relevant financial relationships to disclose.
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Former Authors

Roger Broughton MD (original author), Christian Guilleminault MD, Stephen H Sheldon DO, Michael J Rack MD, and Mari Viola-Saltzman DO

Patient Profile

Age range of presentation: 0 month to 65+ years
Sex preponderance: male>female, >2:1
Heredity: none
Population groups selectively affected: none selectively affected
Occupation groups selectively affected: Drivers

Military

ICD & OMIM codes

ICD-9: Coma: 780.01

Hypersomnia: 780.54

Insomnia: 780.52

Narcolepsy: 347.00

Obstructive sleep apnea: 327.23

Periodic limb movement disorder: 327.51

Sleep disorder: 780.50

Sleeplessness: 780.52
ICD-10: Coma: R40.2

Hypersomnia: G47.1

Insomnia: G47.0

Narcolepsy: G47.4

Obstructive sleep apnea: G47.33

Periodic limb movement disorder: G47.61

Sleep disorder: G47.9

Sleeplessness: G47.0

Traumatic brain injury: S06.890A

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Posttraumatic sleep disturbance

Associated Disorders

Excessive daytime sleepiness
Hypersomnolence
Posttraumatic hypersomnia
Posttraumatic insomnia
Posttraumatic narcolepsy
- Posttraumatic narcolepsy-cataplexy
- Sleep disorders associated with craniocerebral injuries
- Sleep disorders associated with dementia pugilistica
- Sleep disorders associated with posttraumatic psychosis
- Sleep disorders associated with posttraumatic syndrome

Differential Diagnosis

prior sleep disturbance of a similar type
occult cases of somnolence
hydrocephalus
subdural hematoma
meningitis
- use of central nervous system depressant anticonvulsant medication
- psychophysiologic insomnia unrelated to head injury
- sleep-disordered breathing
- disorders of hypersomnia

Also Relevant

Dementia pugilistica
Gulf War syndrome
Headache attributed to head trauma
Hypersomnolence
Idiopathic hypersomnia
- Insomnia
- Irregular sleep-wake rhythm disorder
- Minor closed head injury
- Narcolepsy
- Non-24-hour sleep-wake disorder
- Obstructive sleep apnea
- Severe closed head injury
- Sleep and dementia
- Sleep and mental disorders
- Sleep disorders
- Sleep terror
- Whiplash injuries

Posttraumatic sleep disturbance

Introduction

Overview

Table 1. Sleep Disturbances Associated with Traumatic Brain Injury

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Diagnostic workup

Management

Insomnia

Hypersomnia

Restless leg syndrome

Sleep related disordered breathing

Outcomes

Media

References

Contributors

Author

Editor

Former Authors

Patient Profile

ICD & OMIM codes

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Questions or Comment?

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