How long should you stay awake after a mild traumatic brain injury/concussion?
It all begins with an idea.
How long do you need to stay awake after a concussion? Should you be woken up throughout the night?
Other common questions:
Do you have to avoid coffee and caffeine after a concussion?
How long after a concussion can you drink alcohol?
Can you take Ibuprofen for a concussion?
FOR FOLKS IN A PINCH, HERE'S THE QUICK ANSWER:
Do not allow the athlete (or concussed individual) to sleep for at least 3 hours after the injury.
May not need to wake the athlete throughout the night, but monitoring them throughout the night is prudent.
The 2019 CCMI Clinician Course recommends that the athlete/concussed individual is checked on throughout the night and only woken if there are concerns about breathing or their overall state. They also remind that the athlete will likely be fatigued due to the growing ATP deficit, per normal concussion pathophysiology.
2004 NATA guidelines recommend waking the athlete throughout the night (every 3-4 hours) only if they have experienced a loss of consciousness, had/have prolonged memory loss, or are still experiencing significant symptoms.
In 2006, concussion researchers, Drs. John Leddy and Bary Willer echoed the NATA recommendations from 2004.
Why are there sleep concerns acutely after a concussion?
Ultimately, we don't want to miss a life-threatening issue (e.g., intracranial hemorrhage or cerebral edema) because our athlete slept through it.
Your doctor, athletic trainer, or concussion specialist on the sidelines or in the ER will consider a set of "rules" to determine if a head CT is needed. These are the Canadian CT Head Rule and the New Orlean's Criteria. The Candian CT Head Rule is likely superior and includes:
Glasgow Coma Score <15 after 2hrs
Suspected skull fracture
Signs of basal skull fracture
Two or more episodes of vomiting
65yo or older
Memory loss before the impact by more than 30min
Dangerous injury mechanism
The bolded signs/symptoms are strong predictors of finding anatomical changes on the CT.
CLARIFICATION:
Signs of a skull fracture include bruising behind the ears (Battle sign), two black eyes (raccoon eyes), blood behind the eardrum, or clear fluid coming from the nose or ears.
A "dangerous mechanism" includes a pedestrian being struck by a vehicle, being ejected from a vehicle, falling from a height of 3ft or more, or falling 5+ stairs.
Everyone made it through the first night. What's next?
It is crucial to be evaluated or re-evaluated by a concussion specialist EARLY after a concussion. For example, the NCAA and professional organizations re-evaluate their athletes within 24-48hrs following concussion to confirm the diagnosis and begin integrative treatments.
Sleep after an acute concussion summary.
Remember, we're not allowing the athlete (or concussed) individual to sleep for at least 3 hours after their injury. We're looking to be sure that they're not declining in this period, outside of the expected fatigue.
There are guidelines for which injured patients are candidates for head and brain imaging, and your doctor, trainer, or concussion specialist should be aware of these.
During the night of the concussion, do monitor and check on the injured individual periodically. However, you do not need to wake them unless you're concerned about their breathing or overall state. 2004-2006 guidelines recommend waking every 3-4 hours if there was a loss of consciousness, prolonged amnesia, or significant and sustained symptoms.
Following the first night, schedule a visit with a concussion specialist within the next 24-48hrs. This visit is essential for confirming the diagnosis, ruling out more severe problems, and beginning the recovery process ASAP.
Do you have to avoid coffee and caffeine after a concussion (mild traumatic brain injury)?
It all begins with an idea.
Quick Summary: The research on caffeine in concussion/mTBI needs to be more extensive. That said, avoiding caffeine in the first minutes to hours after a concussion is best. After the acute period of 24-72hrs, however, so long as caffeine is consumed in "normal doses" (100-300mg/day) before 12pm ("noon"), it likely will not impact recovery for better or worse. It's important to note that caffeine withdrawal symptoms closely match some concussion symptoms (e.g., headache, drowsiness, and difficulty concentrating). On the flip side, caffeine can improve visual processing speed, reaction time, and memory, and we do not know if the effect is strong enough to create premature clearance decisions for return to sport.
Other common questions:
How long after a concussion can you drink alcohol?
Can you take Ibuprofen for a concussion?
How long should you stay awake after a mild traumatic brain injury/concussion?
Let's break this down a bit.
Caffeine is arguably the world's most popular drug, with roughly 87% of American adults consuming caffeine (mostly from coffee and tea). Interestingly, 36-56% of North American children consume caffeine. According to the data from the US military, caffeine is a stimulant that will cause beneficial cognitive and physical endurance effects in nearly everyone at doses between 100-600mg. While "caffeine addiction" is not an official substance use disorder, folks can develop tolerance and withdrawal symptoms (e.g., headaches, drowsiness, and difficulty concentrating). Note that those withdrawal symptoms can look a lot like concussion symptoms.
The stimulating benefits and addictive nature are why many folks ritually reach for their cup of coffee every morning - and wonder if they can continue to do so after a concussion.
Theoretical drawbacks of caffeine after concussion/mTBI.
The punchline is that the acute ingestion of caffeine may worsen the glutamate and calcium excitotoxicity of concussion. We don't like that.
Caffeine works by blocking adenosine receptors (e.g., A1 and A2 receptors). A simple and practical example of why this matters is when we consider sleep. As the molecule adenosine builds up throughout the day, it binds adenosine receptors and makes us feel sleepy (i.e., "sleep drive"). So, when we drink coffee with caffeine, it blocks adenosine from binding to its receptors, stimulating us and keeping us from feeling sleepy.
This random image is from “Why We Sleep” by Dr. Matthew Walker
In the context of concussion... Adenosine binds to its A1 receptors, which helps lower glutamate and inflammatory cytokine release. We know that part of the excitotoxicity in concussion is due to an excessive release of glutamate, so adenosine lowering this release could lessen this excitotoxic damage. But, the acute ingestion of caffeine may block these adenosine receptors and dampen the beneficial effects.
Additionally, part of the problem during the excitatory phase of a concussion is the indiscriminate flow of calcium. Calcium ends up "flooding" our mitochondria and dramatically impairing our brain's ability to produce energy (ATP). Caffeine can activate cell messenger systems that increase calcium inside the cell through fancy secondary messenger mechanisms.
Caffeine and return-to-play (RTP) after a sports-related concussion.
Caffeine supplementation (e.g., caffeine pills or coffee consumption) has repeated and known cognitive performance benefits. When looking at concussions specifically, we see improvements in ImPACT scores. The ImPACT test is a computerized neurocognitive test used in baseline testing and by many organizations when making RTP decisions.
While the improvements in reaction time, visual processing, and memory are minor, this may falsely make a player look back to baseline or be ready to play when they are not.
A quick note on chronic consumption of caffeine.
My coffee drinkers may be worried, "But I drink caffeine every day; is that a problem? Would that make a future concussion worse?"
On the contrary, that might be a good thing. Coffee may have legitimate health benefits in average doses of 1-2 cups per day (100-300mg caffeine daily). And from a TBI perspective, we see that chronic caffeine consumption increases your number of adenosine receptors. So, when adenosine is released in a TBI, there are more places to bind and regulate glutamate and calcium release. But, this adenosine release has different effects depending on TBI severity.
Don't confuse severe TBI and mild TBI (concussion).
Research or articles may suggest caffeine's acute benefit in traumatic brain injuries (TBIs). This acute benefit is only seen in severe TBI. In severe TBI, we find benefits from caffeine binding up adenosine receptors. That's because, in severe TBI, so much adenosine can is released, binding so many receptors that it actually slows down your breathing to a lethally slow rate. In these instances, caffeine preventing adenosine from binding its receptor can save your life by preserving your breathing ability. However, severe TBI is significantly different from mild TBI (i.e., concussion).
Quick summary and recap:
We cannot recommend caffeine for concussion recovery, as the evidence doesn't exist, and it may provide falsely good RTP scores. That said, it likely won’t harm your recovery when consumed after the acute period of 24-72 hours.
Caffeine is a stimulant that works by binding/blocking adenosine receptors, and roughly 87% of Americans consume caffeine.
When consumed acutely (minutes to hours) after an mTBI/concussion, it might promote excitotoxicity (bad thing).
When consumed chronically (i.e., regular coffee drinkers), there may be benefits from increased adenosine receptors (good thing) - and we don’t want to block these acutely by consuming caffeine.
The benefits of acute caffeine ingestion seen in severe TBI do not translate to mild TBI (i.e., concussion).
References:
Abalo, R. (2021). Coffee and caffeine consumption for human health. Nutrients, 13(9), 2918.
Lusardi, T. A., Lytle, N. K., Szybala, C., & Boison, D. (2012). Caffeine prevents acute mortality after TBI in rats without increased morbidity. Experimental neurology, 234(1), 161-168.
Lusardi, T. A., Lytle, N. K., Gebril, H. M., & Boison, D. (2020). Effects of Preinjury and Postinjury Exposure to Caffeine in a Rat Model of Traumatic Brain Injury. Journal of Caffeine and Adenosine Research, 10(1), 12-24.
National Research Council. (2001). Caffeine for the sustainment of mental task performance: Formulations for military operations. Washington, DC: National Academy Press, 6, 104-168.
Powers, M. E. (2015). Acute stimulant ingestion and neurocognitive performance in healthy participants. Journal of athletic training, 50(5), 453-459.
Trojian, T. H., Wang, D. H., & Leddy, J. J. (2017). Nutritional supplements for the treatment and prevention of sports-related concussion—evidence still lacking. Current sports medicine reports, 16(4), 247-255.
Website/Database: https://examine.com/supplements/caffeine/