Medications such as stimulants (methylphenidate, dextroamphetamine, modafinil, armodafinil) are helpful in hypersomnia [38], circadian rhythm disorder [39], and narcolepsy [32] by promoting wakefulness during the day. Supplementation with melatonin is also helpful in patients with insomnia [37], and circadian rhythm disorder [39]. Amantadine is helpful in improving alertness in some TBI patients. It has been shown that TBI patients treated with amantadine reported improvements in motivation, attention, concentration, alertness, and executive functioning; reduced apathy, agitation, distractibility, fatigue, aggression, and anxiety have also been reported [41]. Iron supplementation, dopamine agonists, or gabapentin can be helpful in cases with periodic limb movement of sleep and/or restless leg syndrome [32].

Forced brain rest/cognitive rest in which the individual with TBI takes plenty of rest is very important and promotes brain healing, and in turn prevents deterioration of any sleep problems. This includes avoiding activities that are physically demanding and those that require a lot of mental concentration, avoiding contact sports, avoiding alcoholic beverages, and instituting good sleep hygiene [42, 43]. Good sleep hygiene involves a combination of set bedtime routines and also habits during the daytime and evening which ensure an optimal sleep environment. It is important to limit daytime, especially evening, naps and to avoid caffeine intake. Limiting evening time visual stimulation and exposure to bright lights (by way of avoiding television screens) will promote good nighttime sleep habits. Limiting evening exposure to television and bright lights is especially helpful because there have been studies demonstrating a decrease in urinary excretion of melatonin metabolites after daily evening exposure to television for 1 week [44] and suppression of melatonin secretion and a reduction of presleep melatonin levels after exposure to bright lights [45]. Maintaining a consistent night-to-night bedtime routine with as little variability as possible is an important part of good sleep hygiene. Once established, most patients will respond well to these bedtime routines.

In conclusion, sleep problems are an under-recognized problem in patients with TBI. Better screening for these disorders and appropriate management will lead to improved quality of life in this population.