A concussion is a mild traumatic brain injury (mTBI) caused by a bump, blow, or jolt to the head that causes the brain to move rapidly inside the skull. This sudden movement temporarily disrupts normal brain function, leading to physical, cognitive, and emotional symptoms. While most concussions resolve without serious complication, the initial hours require monitoring for rare but serious complications. Public confusion persists, as many people still believe a person with a concussion must be constantly woken up.
The Modern Approach to Overnight Monitoring
Current medical consensus moves away from continuous, forced waking for most people who have sustained a concussion. Rest, including uninterrupted sleep, is necessary for the brain to begin its initial healing process. Sleep allows the body to clear metabolic waste and perform cellular repair, functions crucial for an impaired brain.
A medical professional determines if monitoring is necessary based on the individual’s symptoms, medical history, and mechanism of injury. If monitoring is advised, the caregiver should check the patient without rousing them from deep sleep. This involves observing their breathing, checking skin color, and assessing their general responsiveness.
If a person needs to be woken, it should be a brief check to confirm they are easily rousable and can answer a simple question, such as their name or the date. For some patients, such as children or those with a higher risk profile, a doctor may advise periodic waking every two to three hours for the first 12 to 24 hours. The frequency of checking is a specific instruction provided by the treating physician, not a standard protocol.
Identifying Red Flags: When Sleep Is Dangerous
The real danger after a concussion is the possibility of a rapidly worsening condition, such as intracranial bleeding or swelling, which can be missed while the person is unconscious. These worsening symptoms, known as red flags, demand immediate emergency medical attention. If any of these signs appear, the immediate need for hospital care supersedes all monitoring protocols.
Neurological Changes
A change in neurological status is a significant warning sign. This includes slurred speech, confusion, or difficulty recognizing people or places. Weakness, numbness, or loss of coordination in the arms or legs suggests severe neurological involvement. Unequal pupil size, where one pupil is noticeably larger than the other, indicates potential pressure on the brain requiring urgent intervention.
Physical Symptoms
Concerning physical signs include a severe headache that continuously worsens or repeated, forceful vomiting. Seizures or convulsions, even a single episode, are a sign of a medical emergency. Also, look for clear or bloody fluid draining from the nose or ears, which can indicate a skull fracture.
Debunking the Myth of Constant Waking
The advice to wake a person with a concussion every hour is largely a remnant of medical practice from before the widespread availability of modern neuroimaging technologies. In past decades, without immediate access to CT scans or MRIs, frequent waking was a crude behavioral test. This test ensured the patient’s level of consciousness was not declining due to a slow, internal brain bleed.
Medical understanding has evolved to recognize that interrupting sleep is detrimental to recovery. Sleep is a restorative process necessary for the brain to heal from the trauma of the injury. Frequent waking disrupts crucial sleep cycles, potentially prolonging symptoms and delaying recovery.
The current standard focuses on preventative education and monitoring for specific red flag symptoms, rather than relying on a disruptive, blanket waking schedule. If a person has been evaluated by a healthcare provider and has no symptoms indicating a severe injury, allowing them to sleep peacefully is the preferred approach. The emphasis has shifted to ensuring a safe environment for the brain to begin healing.
General Guidelines for Initial 24-Hour Care
The initial 24 hours following a concussion should focus on physical and cognitive rest to minimize strain on the injured brain. Cognitive rest involves limiting activities that require concentration or mental effort, such as reading, using computers, or watching television. While complete rest is no longer recommended, relative rest is beneficial, meaning light activity is acceptable as tolerated.
Pain Management and Diet
For pain management, acetaminophen (Tylenol) is safe for headaches in the acute phase after a concussion. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin) and aspirin should be avoided in the first 24 to 48 hours due to the risk of increasing bleeding. Hydration and maintaining a normal diet are important, as dehydration or low blood sugar can worsen headache symptoms.
Safety and Monitoring
The injured person should not be left alone during the first 12 to 24 hours to ensure a responsible person is available to monitor for changes in condition. Avoid alcohol, recreational drugs, and unprescribed sleeping aids, as these substances can mask symptoms or interfere with the brain’s natural healing process. Light physical activity, such as a short walk, is acceptable if it does not increase symptoms.