1
DoD Clinical Recommendation | June 2020
Management of Sleep Disturbances Following Concussion/mTBI: Guidance
for Primary Care Management in Deployed and Non-Deployed Settings
Introduction
Sleep disturbances are commonly associated with concussion or mild traumatic brain injury (mTBI) in the acute, sub-
acute, and chronic recovery stages. The prevalence of sleep disorders is higher among individuals with mTBI compared
to the general population.
1,2
The most common sleep disorders associated with mTBI include insomnia, obstructive
sleep apnea (OSA), circadian rhythm sleep-wake disorders (CRSWD), restless legs syndrome (RLS), and parasomnias.
3,4
Evidence is lacking regarding the prevalence of shift work disorder (SWD) and insufcient sleep syndrome (ISS) in mTBI;
however, these disorders are included in this recommendation because they are common in the military population and
could impede recovery from mTBI. Addressing sleep early after mTBI is imperative to promoting recovery and preventing
chronic mTBI symptoms.
5,6
Step 1: Focused Sleep Assessment
As part of a sleep history, primary care managers (PCMs) should consider asking the following screening questions to
identify sleep disorders after mTBI.
Contributing Factors (See Step 3)
Have you ever received treatment for a sleep disorder? Have you ever had a sleep study? If so, when, where, and
what was the result?
Have you had any recent stressful events that may be affecting your sleep? (e.g. familial changes, nancial stress,
safety concerns)
Do you nap during the day? If so, how frequently, for how long, and at what time of day?
Are you now or have you ever received treatment for a psychological health condition, such as depression, anxiety,
substance use disorder, or post-traumatic stress disorder (PTSD) or a medical condition, such as chronic pain?
Have you had any recent changes to your medications, including over the counter medications or supplements?
How many caffeinated or “energy” beverages do you consume per day? How many alcoholic beverages do you
consume per week?
Excessive Daytime Sleepiness
Do you have difculty staying awake during the day?
Do you have any concerns about your ability to drive, operate machinery, or carry a weapon safely?*
Note: Excessive daytime sleepiness with increased sleep need is common in the immediate and acute stages of mTBI
and typically improves by following a structured approach for gradual return to baseline activity. Guidelines for
treatment and return to activity in the acute stage following mTBI can be found in the TBICoE Progressive Return
to Activity Clinical Recommendation. If excessive daytime sleepiness persists beyond 2-4 weeks following mTBI,
other underlying etiologies should be thoroughly investigated (e.g. insomnia, obstructive sleep apnea, circadian
rhythm sleep-wake disorder, pain, depression).
Insomnia (pg. 4)
Do you have difculty falling asleep or staying asleep?
How long does it take you to fall asleep?
How many times do you wake up throughout the night?
Obstructive Sleep Apnea (pg. 5)
Do you snore or stop breathing/gasp during sleep or
have you been told you do?
Do you feel well-rested in the morning?
Insufficient Sleep Syndrome (pg. 6)
On average, how many hours do you sleep per night?
Consider work days versus days off.
Do you feel like you get an adequate amount of sleep?
If not, why?
Restless Legs Syndrome (pg. 6)
Do you have an urge to move and/or discomfort in your
legs that is keeping you awake at night?
Circadian Rhythm Sleep-Wake Disorders (pg.7)
If you have the opportunity to sleep on your own
schedule, do you feel well rested?
Has there been a recent change in your sleep patterns?
(e.g. shift work, deployment)
Parasomnias (pg. 8)
Do you have nightmares?
Do you or your sleeping partner notice unusual or troubling
events during sleep?*
(e.g. sleepwalking, verbalizations,
purposeful movements)
*Positive response may indicate a Red Flag and requires further investigation (see Step 2).
2
DoD Clinical Recommendation | June 2020
Management of Sleep Disturbances Following Concussion/mTBI:
Guidance for Primary Care Management in Deployed and Non-Deployed Settings
Step 2: Rule Out Red Flags
If any of the following Red Flags are detected during the focused sleep assessment, immediate referral is indicated.
Step 3: Consider Contributing Factors
Maladaptive sleep behaviors, comorbid conditions, and certain medications can exacerbate or cause sleep disturbances,
complicating the presentation and diagnosis of sleep disorders. Emphasis should be placed on a multidisciplinary
treatment approach and communication among the care team.
Red Flag Referral
Psychological symptoms with concern for danger to self or
others
Psychological Health/ Emergency Department
Sleep behaviors that are potentially injurious to self or
others (e.g. sleepwalking, dream enactment behaviors)
Sleep Medicine
Inability to stay awake or subjective sleepiness while
driving, operating machinery, or handling weapons*
Sleep Medicine
* Concerns regarding the patient’s ability to stay awake may warrant assessment with the Epworth Sleepiness Scale.
Addressing Maladaptive Sleep Behaviors: Healthy Sleep Practices
The American Academy of Sleep Medicine and Sleep Research Society recommend at least 7 hours of sleep on a
regular basis to promote optimal health
7
Avoid stimulants such as caffeine, nicotine, and energy drinks at least 6 hours before bedtime
Avoid alcohol within 2 hours of bedtime due to negative impact on sleep architecture
Exercise regularly, but avoid exercising within 2 hours of bedtime
Limit large/heavy meals and excessive uid close to bedtime
Promote a sleep friendly environment: minimize noise and light and maintain a cool but comfortable temperature
Avoid use of smart-phones and other light emitting devices within 2 hours of bedtime (light suppresses melatonin
synthesis and secretion); use the night setting/blue light lter on devices when available
Use bedroom only for sleep and intimacy
Get exposure to natural light every morning
Limit naps to ≤ 30 minutes in length and ≥ 7 hours prior to desired sleep time
Healthy sleep practices are broadly applicable and should be encouraged after mTBI but are not a stand-alone
treatment for any specic sleep disorder.
3
DoD Clinical Recommendation | June 2020
Management of Sleep Disturbances Following Concussion/mTBI:
Guidance for Primary Care Management in Deployed and Non-Deployed Settings
Step 4: Diagnosis and Management
Pages 4-8 present diagnostic criteria, relevant assessments, treatment options, and referral considerations for the most
relevant sleep disorders after mTBI:
Insomnia
Obstructive Sleep Apnea
Insufcient Sleep Syndrome
Restless Legs Syndrome
Circadian Rhythm Sleep-Wake Disorders
Parasomnias
Step 5: Disposition
Consider the functional impact of sleep disorders and medications on the service member’s ability to perform the mission
and risk of harm to self or others. Certain conditions and/or medications can impact deployability and restrict duty status.
Policies and procedures are service and command specic. Refer to appropriate prescribing specialist and consult duty
and deployment standards for your organization when dispositioning patient.
mTBI Comorbidities
Implicated in Sleep
Disturbances
Post-Traumatic Stress Disorder
Generalized Anxiety Disorder
Panic Disorder
Major Depressive Disorder
Adjustment Disorder
Substance Abuse Disorder
Attention Decit Hyperactivity
Disorder
Headaches
Chronic pain
Cognitive complaints
Seizure disorder
Endocrine abnormalities
(e.g.
hypopituitarism, hypothyroidism,
adrenal insufciency)
Providers should consider
early referral in patients with
pre-existing sleep and/or
psychological health conditions.
Medications and Supplements that Can Interfere with Sleep
Activating
Antidepressants, beta-adrenergic drugs used to treat
asthma, stimulants (amphetamine), glucocorticoids,
caffeine, nicotine
Sedating/
exacerbate sleep
apnea
Sedating antidepressants, sedative-hypnotics,
benzodiazepines, opioids, barbiturates, antipsychotics,
antiepileptics, diphenhydramine, alcohol
Precipitate/
exacerbate
restless legs
syndrome
Antidepressants, dopamine-blocking antiemetics
(metoclopramide), antipsychotics, diphenhydramine,
pseudoephedrine, caffeine
Precipitate/
exacerbate
nightmares
Antidepressants and sedative-hypnotics (upon
initiation and discontinuation), dopaminergic agents
(pramipexole, amphetamine, methylphenidate), lipophilic
beta blockers (metoprolol, propranolol), withdrawal
from: alcohol, benzodiazepines, barbiturates
Precipitate/
exacerbate
dream enactment
behaviors
Antidepressants, withdrawal from: alcohol,
benzodiazepines, barbiturates
If polypharmacy is present, particularly multiple psychoactive medications,
consider priority referral to the prescribing psychological health provider.
4
DoD Clinical Recommendation | June 2020
Management of Sleep Disturbances Following Concussion/mTBI:
Guidance for Primary Care Management in Deployed and Non-Deployed Settings
Precautions & Contraindications
Benzodiazepines - Contraindicated following TBI: Use may impede neuronal recovery and negatively impact cognitive function.
22
Non-benzodiazepine sedative-hypnotics: As individuals with TBI have a higher reported rate of parasomnias, the use of non-
benzodiazepine sedative-hypnotics should be minimized/used with caution in this population.
FDA Boxed Warning: Serious side effects including death due to complex sleep behaviors such as sleepwalking or sleep driving.
Contraindicated in patients who previously experienced complex sleep behaviors. Behaviors can occur at the lowest dose, after just one
dose, and with or without concomitant alcohol or other CNS depressants. (Zolpidem may have higher risk of complex sleep behaviors).
23
Caution: Non-benzodiazepine sedative hypnotics may interfere with cortical plasticity,
24
and long-term use (>30 days) can result in
tolerance, dependence or abuse.
Caution: All non-benzodiazepine sedative-hypnotics carry a risk of next-day psychomotor impairment. This risk is increased at higher
doses, if taken with less than a full night of sleep (7 to 8 hours), and with longer acting agents (e.g. eszopiclone). Avoid use in
irregular/unpredictable sleep-wake schedules/environments.
Caution: Zolpidem has more CNS adverse effects (e.g. somnolence, hallucinations) reported compared to eszopiclone,
25
and
zolpidem has been implicated in more emergency department visits (e.g. falls, head injuries) than any other psychiatric medication.
26
Anticholinergics - Caution: Minimize use within 3 months of TBI due to risk of cognitive impairment. Note: Doxepin is a TCA
with anticholinergic activity at doses ≥ 25mg. Conversely, low dose doxepin is selective for H1 receptors, and no to very minimal
anticholinergic side effects have been reported.
27
Insomnia
Insomnia is the most common sleep disturbance in the mTBI population.
8
Short-term [F51.02]: Symptoms present < 3 months
9
(often occurs in response to an identiable stressor [e.g. mTBI])
Chronic [F51.01]: Symptoms occur at least 3 times/week and persist for at least 3 months
9
Diagnostic Criteria Evaluation Treatment Recommendations
Diagnostic criteria A-D must be met:
A.
One or more of the following:
1. Difculty initiating sleep
2. Difculty maintaining sleep
3. Waking up earlier than desired
4. Resistance to going to bed on appropriate
schedule
5. Difculty sleeping without parent or
caregiver intervention
B. One or more of the following related to
nighttime sleep difculty:
1. Fatigue/malaise
2. Attention, concentration, or memory impairment
3. Impaired social, family, occupational, or
academic performance
4. Mood disturbance/irritability
5. Daytime sleepiness
6. Behavioral problems (e.g. hyperactivity,
impulsivity, aggression)
7. Reduced motivation/energy/initiative
8. Proneness for errors/accidents
9. Concerns about or dissatisfaction with sleep
C
. The reported sleep/wake complaint
cannot be explained purely by inadequate
opportunity (i.e. enough time is allotted for
sleep) or inadequate circumstances (i.e.
environment is conducive to sleep)
D. The sleep/wake difculty is not better
explained by another sleep disorder
9
(e.g. ISS, CRSWD)
Insomnia
Severity Index
(ISI)
10,11
Scoring Criteria:
> 14: Clinical
insomnia
> 11: Clinical
insomnia in
mTBI
12
Non-Pharmacologic (preferred)
- Cognitive Behavioral Therapy for Insomnia
(CBT-I) or Brief Behavioral Treatment for
Insomnia (BBTI):
13-15
see mobile resources for
“Path to Better Sleep” and “CBT-I Coach” if a
qualied provider is not available
- Review Healthy Sleep Following Concussion/
mTBI with patient*
- Auricular acupuncture with seed and pellet
16
Pharmacologic
- Sleep maintenance:
- Doxepin: 3-6mg 30 min prior to bedtime for
14-28 days**
- Sleep onset & maintenance:
17
- Eszopiclone: 1mg at bedtime for 14 days
- Z olpidem: 5mg at bedtime for 14 days
17
- Sleep onset:
- Zaleplon: 5-10mg at bedtime for 14 days***
Additional treatment options
- Melatonin (high quality): 1-5mg (3mg usual
dose) 60-90min before bedtime
Referral Criteria
Refer to a qualied CBT-I or BBTI provider
Refer to Sleep Medicine if insomnia symptoms persist beyond a
2-4 week medication trial
Consider early Sleep Medicine referral in patients with pre-existing
sleep condition
Consider early Psychological Health referral in patients with a
comorbid psychological health condition
* Use only in conjunction with other appropriate interventions, such as CBT-I or BBTI, and not as a stand-alone
treatment for insomnia.
18,19
** Doxepin: 3-6mg formulation is only available as brand Silenor; generic options include a 10mg capsule and a 10mg/
ml solution.
*** Zaleplon: consider using this short-acting agent rather than longer acting agents in operational environments with
unpredictable sleep-wake schedules (can be administered up to 4 hours before the anticipated wake time).
20,21
5
DoD Clinical Recommendation | June 2020
Management of Sleep Disturbances Following Concussion/mTBI:
Guidance for Primary Care Management in Deployed and Non-Deployed Settings
Obstructive Sleep Apnea (OSA) [G47.33]
OSA is estimated to occur in one-third or more of service members with a history of TBI.
28-30
An increased prevalence of OSA with comorbid insomnia has also been noted in the military population.
31,32
Diagnostic Criteria Evaluation Treatment Recommendations
Polysomnography (PSG) reported Apnea-
Hypopnea Index (AHI) ≥ 5 per hour of sleep plus
one or more of the following:
1. Daytime sleepiness, nonrestorative sleep,
fatigue, or insomnia symptoms (recurrent
awakenings)
2. Waking up with breath-holding, gasping, or
choking
3. Witnessed snoring [R06.83], breathing
interruptions, or both during sleep
4. Conditions and/or complications associated
with OSA: HTN, mood disorder (PTSD),
33
cognitive dysfunction, CAD, stroke, CHF,
AFib, T2DM
OR
PSG reported AHI ≥ 15 per hour of sleep
regardless of the presence of associated
symptoms or comorbidities
9
STOP-BANG
Questionnaire*
34
Physical Exam: Typically
normal in Active Duty
Service Member
35,36
-Overweight (BMI >
25kg/m
2
)
- Neck circumference: ≥
16” female; ≥ 17” male
-Excessive oropharyngeal
tissue (Mallampati
classication)
37
-Retrognathia
38
Treatment to be initiated and
managed by Sleep Medicine and
typically includes: Continuous
Positive Airway Pressure (CPAP)
therapy, oral appliance therapy
(mandibular advancement devices
[MADs])
Review CPAP Adherence Pearls**
Behavioral modications: weight
loss, alcohol avoidance, smoking
cessation
Referral Criteria
See below for referral based on STOP-BANG screening results*
Ensure follow-up with Sleep Medicine 4 weeks after therapy
initiation, then at least annually
Deployment/Remote Duty Station Considerations
Portable treatment options: MADs, expiratory positive airway pressure (EPAP) devices, and portable PAP machines
Treatment options for suspected OSA without access to Sleep Medicine: Non-supine positional therapy, such as tennis ball
on the back or an alarm device when supine,
42
(may be appropriate in younger patients with supine disease who have
mild OSA and are not obese);
43
inhaled nasal steroids for chronic congestion; discontinuation of sedating medications;
behavioral modications
**CPAP Adherence Pearls
1. Desensitization strategies: wear positive airway pressure (PAP) mask while watching TV/relaxing at night for
several nights prior to connecting to the machine. Patients with comorbid PTSD may also benet from prazosin
therapy.
2. Appropriate use of inhaled nasal steroids for indicated conditions such as chronic nasal congestion due
to rhinitis or nasal polyps. (Use in the absence of these conditions has not been shown to improve PAP
adherence).
39
3. Educational, behavioral, and supportive interventions (e.g. CBT, motivational interviewing, and education on CPAP
benets and OSA risks) can improve adherence.
40,41
*Recommended STOP-BANG Interpretation for Service Members and Veterans
OSA Risk Scoring Interpretation
Low 0-2 Yes responses
Refer to Sleep Medicine ONLY if other
diagnostic criteria are present
Intermediate 3-4 Yes responses
Refer to Sleep Medicine
High 5-8 Yes responses
High ≥ 2 Yes to the STOP questions & BMI >35 kg/m
2
High
≥ 2 Yes to the STOP questions & neck
circumference ≥17” male or ≥16” female
High ≥ 2 Yes to the STOP questions & male gender
6
DoD Clinical Recommendation | June 2020
Management of Sleep Disturbances Following Concussion/mTBI:
Guidance for Primary Care Management in Deployed and Non-Deployed Settings
Precautions
Caution: Dopaminergic agents (pramipexole, ropinirole) are not recommended in TBI population due to the potential to
precipitate/exacerbate parasomnias and behavioral disturbances such as impulse control.
Insufficient Sleep Syndrome (ISS) [F51.12]
Insufcient sleep syndrome is prevalent in the military population due to unique stressors (e.g. high operational
tempo)
44
and should be considered in patients presenting with depression, fatigue, and lethargy. Symptoms can often
be misattributed to insomnia; however, patients with insufcient sleep syndrome will fall asleep rapidly given the
opportunity.
Diagnostic Criteria Evaluation Treatment Recommendations
Diagnostic criteria 1-6 must be met:
1. Daily periods of irrepressible need to sleep
or daytime lapses into sleep
2. Sleep time is usually shorter than expected
for age
3. Curtailed sleep pattern present most days
for ≥ 3 months
4. Sleep time is curtailed by measures, such
as an alarm clock, and sleep time is longer
when these measures are not used, such as
on weekends or vacations
5. Extension of total sleep time results in
resolution of sleepiness symptoms
6. Symptoms are not better explained by
medication, substance use, or other
medical disorder
9
AASM Sleep Diary
45
Non-Pharmacologic
- Lifestyle or shift work modications to
allow for sufcient sleep time
- Review Healthy Sleep Following
Concussion/mTBI with patient
Pharmacologic
- None recommended
Referral Criteria
Refer to Sleep Medicine if unresponsive to treatment
Restless Legs Syndrome (RLS) [G25.81]
Diagnostic Criteria Evaluation Treatment Recommendations
Essential diagnostic criteria (all must be met):
1. Urge to move the legs (sometimes arms) that
is usually associated with uncomfortable
and unpleasant sensations
2. Symptoms start or become worse with rest
or inactivity
3. At least partial relief of symptoms occurs
with physical activity
4. Symptoms only occur or are worse in the
evening or at night
5. Symptoms are not solely explained by
another medical or behavioral condition (e.g.
myalgia, venous stasis, leg edema, arthritis,
leg cramps, positional discomfort, habitual
foot tapping)
Specier for clinical signicance of RLS:
Symptoms cause signicant distress or
impairment in important areas of functioning
due to impact on sleep, energy, daily activities,
behavior, cognition, or mood
46
Labs: Iron panel with
Ferritin
Non-Pharmacologic
- Warm compresses to affected area
- Weighted blanket
- Compression stockings at night
Pharmacologic
- If ferritin level ≤ 75mcg/L: Ferrous
sulfate 325mg (65mg elemental iron)
in combination with Vitamin C 100-
200mg, twice daily
47
- Gabapentin: 100mg-300mg 2 hours
prior to bedtime; increase dose every
1-2 weeks until symptom relief, up to
1.2-1.8g/day
48-50
- G abapentin enacarbil (sustained
release): 600mg once daily at ~5pm
Referral Criteria
Refer to Sleep Medicine if unresponsive to treatment
7
DoD Clinical Recommendation | June 2020
Management of Sleep Disturbances Following Concussion/mTBI:
Guidance for Primary Care Management in Deployed and Non-Deployed Settings
Circadian Rhythm Sleep-Wake Disorder (CRSWD) [G47.20]
Symptoms of CRSWDs are often misattributed to insomnia.
51,52
Diagnostic Criteria
The following general criteria must be met, as well as the subtype criteria below:
1. Chronic or recurrent disrupted sleep-wake pattern due to misalignment (extrinsic) or malfunction (intrinsic) of the
circadian system as evidenced by sleep diary and (if possible) actigraphy monitoring for 7-14 (work and free) days
2. Insomnia, excessive daytime sleepiness, or both
3. Symptoms cause clinically signicant distress or impairment in important areas of functioning
4. Symptoms are present for ≥ 3 months
5. The sleep-wake disturbance is not better explained by medication, substance use, or other medical disorder
9
CRSWD Subtype Criteria
Evaluation
Treatment
Recommendations
Referral Criteria
Delayed Sleep-Wake Phase
Disorder [G47.21]
- Delay (≥ 2 hours) in the
timing of habitual sleep
period compared to
conventional or required
sleep-wake times
- Unlike insomnia, when
allowed to adhere to
preferred sleep-wake
schedule, patients will
report improved sleep
quality/quantity
AASM Sleep Diary
45
Actigraphy
Non-Pharmacologic
- Strategically timed short
wavelength blue light
(~480nm) therapy
53,54
and
avoidance of light prior to
bedtime
Pharmacologic
- Melatonin (high quality):
0.5-5mg (usual dose:
3mg) 1-2 hours before
bedtime
55
Refer to Sleep Medicine
if inadequate response
to initial treatment after
8 weeks
Consider comorbid
depression and referral
to Psychological Health
Shift Work Disorder [G47.26]
- Reduction in total sleep
time associated with a
reoccurring work schedule
that overlaps with the
usual time for sleep;
also consider poor sleep
hygiene
AASM Sleep Diary
Actigraphy
Consider impact of light
exposure if possible
Non-Pharmacologic
- Strategically Timed Naps:
≤ 30 minutes in length ≥
7 hours prior to desired
sleep time
Pharmacologic
- Melatonin (high quality):
0.5-3mg 30 minutes
before bedtime
56
Refer to Sleep Medicine
if inadequate response
to initial treatment after
4 weeks
Irregular Sleep-Wake Rhythm
Disorder [G47.23]
- No major sleep period and
at least 3 irregular sleep
periods during a 24 hour
timeframe
AASM Sleep Diary
Actigraphy
Treatment to be initiated
and managed by Sleep
Medicine
Refer to Sleep Medicine
Consider comorbid
depression and referral
to Psychological Health
Precautions
Blue Light Therapy Precaution: Inaccurate timing can worsen sleep issues; avoid prior to desired bedtime. Use
no more than 2 hours before patient’s desired wake time. Refer to Sleep Medicine for guidance on proper use.
8
DoD Clinical Recommendation | June 2020
Management of Sleep Disturbances Following Concussion/mTBI:
Guidance for Primary Care Management in Deployed and Non-Deployed Settings
Parasomnias
Parasomnias: A category of sleep disorders that involve undesirable physical events or experiences that occur while
falling asleep, sleeping, or waking from sleep. Parasomnias can be precipitated/exacerbated by sleep deprivation or
fragmentation, both common after mTBI.
Diagnostic Criteria Treatment Recommendations Referral Criteria
Confusional Arousals
1. Episodes of mental confusion or disoriented behavior
during an arousal or awakening from sleep
2. Behaviors include nonsensical verbalizations and
non-purposeful movements
3. Patients typically have no memory of the event
Most commonly caused by unhealthy sleep practices
Non-Pharmacologic
- P rovide reassurance on the benign
nature
- Review Healthy Sleep Following
Concussion/mTBI with patient;
emphasize abstaining from alcohol
None indicated
Consider referral to
Sleep Medicine if
symptoms persist
Sleepwalking [F51.3]
1. Begins as a confusional arousal followed by
ambulation from bed
2. Slow and quiet ambulation, occasionally with more
agitated behaviors
3. Patients typically have no memory of the event
Non-Pharmacologic
- Create safe bedroom
environment, to include locking
doors and securing weapons
- Sleep separately from bed
partner if risk of injury
Immediate Referral
to Sleep Medicine
Sleep Paralysis
1. Partial or complete temporary inability to move or
call out, often accompanied by hallucinations
2. Vivid and frightening visual, tactile, or auditory hallucinations
3. Occurs upon awakening or falling asleep
4. Patients are able to recall the event
Patients may report event as a nightmare
Non-Pharmacologic
- Provide reassurance on the
benign nature
- Review Healthy Sleep Following
Concussion/mTBI with patient
None indicated
Consider referral
to Sleep Medicine
only if symptoms
persist or cause
signicant distress
Trauma Related Nightmares (TRN)
1. Recurrent dysphoric, well-remembered dreams
with vivid, distressing content that is related to a
traumatic event(s)
57
2. Results in disturbed, fragmented sleep
Nightmares are often underreported by military personnel
and are associated with increased suicidal ideation.
Patients may report insomnia symptoms due to attempts
to avoid sleep and/or frequent awakenings.
57, 5 8
Non-Pharmacologic
- Review Healthy Sleep Following
Concussion/mTBI with patient
- Imagery Rehearsal Therapy
(refer to Psychological Health)
Pharmacologic
-Prazosin: Proper titration
required*
Refer to
Psychological Health
as nightmares may
be secondary to
PTSD
59,60
If no response to
prazosin by 8 weeks,
consider referral to
Sleep Medicine
REM Sleep Behavioral Disorder (RBD) [G47.52]
1. Repeated episodes of dream enactment behaviors
including vocalization and/or purposeful body
movements (e.g. ghting or struggling)
2. Episodes occur during REM sleep as determined by
PSG or clinical history of dream enactment behaviors
3. PSG shows REM sleep without atonia
4. Absence of or distinguishable from epileptiform activity
5. The sleep disturbance is not better explained by
medication, substance use, or other medical disorder
9
Patients are typically able to recall the event
Trauma Associated Sleep Disorder is a novel parasomnia
similar to RBD. In addition to symptoms seen in RBD,
there is an inciting traumatic experience, clinical features
of trauma related nightmares, and sympathetic activation
(tachycardia, night sweats).
61,62
Non-Pharmacologic
- Create safe sleep environment
to include locking doors and
securing weapons
- Sleep separately from bed
partner if risk of injury
Immediate Referral
to Sleep Medicine
*Prazosin Titration
Initially 1mg at bedtime; after 2-3 days increase dose to 2mg; titrate dose by 1-5mg every 7 days up to max 10mg/day
in females and 15mg/day in males
Typical effective adult dosing range: 4-8mg (most patients require greater than 5mg/night)
Note: While evidence is equivocal, prazosin has demonstrated benet in the active duty population.
63-68
9
DoD Clinical Recommendation | June 2020
Management of Sleep Disturbances Following Concussion/mTBI:
Guidance for Primary Care Management in Deployed and Non-Deployed Settings
Additional Resources
Patient Handout
Healthy Sleep Following Concussion/mTBI
Assessment Tools
1. Epworth Sleepiness Scale
2. Insomnia Severity Index
Mobile Resources
The DoD and VA provide several free apps that may help you improve your sleep:
1. Cognitive Behavioral Therapy for Insomnia (CBT-I) Coach: Includes a sleep diary that can help you pinpoint behaviors
that are contributing to your sleep problems; also provides interactive exercises to learn how to adopt positive sleep
habits and guide you through progressive muscle relaxation
2. Mindfulness Coach: Provides nine different guided mindfulness exercises and strategies for overcoming challenges
to mindfulness practice
3. Breathe2Relax: Provides instruction on diaphragmatic “belly” breathing, which helps lower stress and reduce
anxiety; graphics, animation, narration, and videos lead you through several breathing exercises
4. Dream EZ: Helps you rewrite nightmares into less disturbing dreams for a better night’s sleep, using the principles
of imagery rehearsal therapy
5. Tactical Breather: Provides guided breathing instruction to gain control over heart rate, emotions and concentration,
during stressful situations
6. Path to Better Sleep: Delivers the core components of CBT-I, takes advantage of natural sleep rhythms to improve
sleep, and includes personalized sleep diary, sleep scheduling, and relaxation exercises
7. VA/DoD Clinical Practice Guideline for the Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea
This clinical recommendation represents a review of currently published literature and expert contributions from clinical
subject matter experts representing the academic, research and civilian sectors; the Defense Department (DoD) Armed
Forces; the Defense Health Agency; and the Department of Veterans Affairs (VA). Provider judgment and operational
requirements may supersede any recommendation for an individual patient.
Additional information and resources can be found on the TBICoE website: Health.mil/TBICoE
The appearance of hyperlinks does not constitute endorsement by the DoD, US Army, or the Defense and Veterans Brain Injury Center of non-U.S. Government sites or the
information, products, or services contained therein. Although the DoD, US Army, or the Defense and Veterans Brain Injury Center may or may not use these sites as
additional distribution channels for Department of Defense information, it does not exercise editorial control over all of the information that you may nd at these
locations. Such links are provided consistent with the stated purpose of this website.
PUID 4014.2.1.2
Released June 2014 | Revised December 2020
by Traumatic Brain Injury Center of Excellence.
This product is reviewed annually and is current until superseded. 800-870-9244 | Health.mil/TBICoE
Click here for full list of references.