Sleep protocol: How to get back to sleep when your brain doesn't cooperate
A sleep hygiene protocol for those with traumatic brain injuries
Difficulty sleeping is one of the most common and most frustrating symptoms after sustaining a traumatic brain injury. Research suggests that up to 72 % of patients experience some sort of sleep disturbance during their recovery journey, and it can compound other concussion symptoms such as fatigue, fogginess, trouble concentrating, headache, etc. Clinical insomnia is thankfully not as common, with only 27% of concussion patients having long term issues.
Unfortunately, even though sleep disturbances are very common after a concussion, there has not been a lot of research on concussion specific protocols for improving sleep quality. But, there are a number of anecdotal steps that you can take that have shown benefit in other conditions such as insomnia.
We are going to break down the sleep hygiene protocol by time of day, because even though you are having trouble getting and staying asleep at night, good sleep at night starts from the second you wake up. If you are trying tom fix bad sleep once you already can’t sleep, you are a step behind and it can make it more difficult than it needs to be.
Daytime Strategies ☀️
Maintain a Consistent Wake Time
Wake up at the same time every day, even on weekends. It helps to “set” your circadian clock to a consistent sleep time 16h from when you woke up.
Avoid “catch-up sleep” that shifts your schedule. We want to get our body used to one big sleep at nighttime rather than multiple short bouts of sleep.
Light Exposure for Circadian Regulation
Get 10–30 minutes of natural light within an hour of waking (outside if possible).
If light-sensitive, start with indirect sunlight or use blue-light filtering glasses outdoors but still aim for exposure.
This helps anchor melatonin rhythms, which are often dysregulated post-TBI.
Physical Activity (as tolerated)
Engage in graded, sub-symptom threshold aerobic exercise (e.g. walking, stationary bike, light jogging if cleared).
Your healthcare provider can help your find the correct exercising heart rate for your recovery stage using the Buffalo Treadmill Test
Exercise earlier in the day is preferred as vigorous activity close to bedtime can worsen symptoms and delay sleep.
Limit Daytime Naps
If feeling overly fatigued, naps can help with reduced symptoms but limit naps to 20–30 minutes and avoid napping after 3 p.m.
Long naps interfere with sleep drive by reseting adenosine levels.
Caffeine & Stimulant Management
Avoid caffeine after 12 p.m. (coffee, tea, energy drinks, pre-workout supplements).
Try and keep total caffeine intake under 200mg a day.
Be cautious with nicotine and other stimulants—they worsen sleep onset.
Monitor screen Time & Cognitive Load
Screens, exercise and cognitively demanding activities do not need to be avoided, but should be done in moderation.
Too much stress on the brain can increase symptoms, overactive your stress response, and make sleep later more difficult. However, moderate activity will help increase sleep drive and can improve sleep at night.
Evening & Pre-Bedtime Strategies 🥱
Wind-Down Routine (30–60 minutes before bed)
Establish a consistent, calming routine: reading, gentle stretching, breathing exercises, or guided relaxation to get your mind and body ready for sleep.
Avoid cognitively or emotionally intense activities before bed (work emails, gaming, social media). They will increase sympathetic nervous system activity and block sleep signals.
Avoid large meals and too many fluids before bed
Finish your last meal 2-3 hours before bed to give your body time to digest and settle before sleep.
Avoiding fluids 1-2 hours before bed can decrease the frequency of bathrooms trips while trying to sleep.
Optimize Your Sleep Environment
You want to keep a dark, cool, quiet bedroom.
Use blackout curtains or an eye mask (especially if photosensitivity persists).
Use white noise or earplugs if noise sensitivity is present. If you suffer from tinnitus, white noise is preferred over earplugs.
Screen & Light Restriction
Avoid screens 1-2 hours before bed.
If use is unavoidable, apply a blue-light filters or put your screen into night mode and dim brightness.
Regulate Body Temperature
Keep your sleep environment around 18–20°C (65–68°F). Your body temperature needs to decrease a couple degrees to induce deeper sleep.
A warm shower or bath 1–2 hours before bed can promote decreasing core body temperature onset via rebound cooling.
Pain & Symptom Management
If headaches, neck pain, or dizziness interfere with sleep, use prescribed pain management strategies 15-30 minutes before bed or as otherwise directed (e.g. relaxation techniques, physical therapy exercises, stretching, meditation, prescribed medication, etc).
A good pillow and mattress can reduce cervical discomfort.
Mind-Body Techniques
Diaphragmatic breathing, progressive muscle relaxation, or mindfulness meditation before bed can reduce hyperarousal and autonomic dysregulation that is common post-concussion.
If racing thoughts are a problem, try scheduled worry time earlier in the evening plus a bedside notepad to offload thoughts.
Avoid alcohol, cannabis and other “non-medical sleep aids”.
While alcohol and cannabis can increase drowsiness, it severely reduces sleep quality and will worsen symptoms the next day.
They decrease REM sleep, alter sleep cycles, and can lead to dependance.
Only use your bed for sleep or romance
You want to create the association in your brain that bed=sleep. Avoid reading, watching TV, scrolling your phone, etc, after you have gotten in bed.
Those activities are ok to do in a quiet, dim room, but it needs to happen outside your bed (desk, couch, comfy chair, etc).
If You Can’t Fall Asleep 😴
Get back out of bed
If you are not asleep within 20 minutes of getting into bed, get out of bed and do a quiet, non-stimulating activity (dim light reading, breathing exercises).
Allow your natural sleep drive to increase again, and return to bed only when sleepy.
This reduces arousal from the frustration of not being able to sleep. Take your mind off not sleeping, do an activity, then try again.
When to Seek Additional Help
If sleep disturbance persists beyond 3–4 weeks, or if insomnia is severe, referral to a sleep medicine specialist or cognitive behavioural therapist for insomnia (CBT-I) therapist is recommended.
Are There Any Supplements That Can Help? 💊
Unfortunately there are no high-quality trails specifically for the use of supplements to improve sleep after a concussion.
There is mild evidence for the short-term use of melatonin (1–5 mg, 30–60 minutes before bed) and may be considered under medical guidance. Some studies suggest it can help TBI-related circadian disruption, though evidence is mixed.
There are some studies suggesting magnesium and L-theanine (from green tea) can improve sleep outcomes in non-concussed populations, but the trials are limited and the effects are small.
Please consult with your healthcare provider before adding any supplements or medications to your routine to ensure safety and the correct dosage.
Take care, stay curious, and happy sleeping!
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