Focus shift in headache therapy

The overall intention of headache therapy is to optimise physical well-being and proactive coping in order to enable participation in meaningful life activities.

The psychotherapeutic elements of this approach aim to reduce physiological stress experiences in order to increase the pain threshold and resilience. Cognitive-behaviour therapy has been shown to optimise psychosocial stress-related conditions and benefit overlapping neural pain mechanisms.

Specifically, the interventions for posttraumatic headaches must focus on pain avoidance behaviour and the reduction of headache fear and distress. These two components are the main drivers for the condition persisting. CBT offers numerous methods and strategies to help a person address these issues as part of their pain management.

Most patients desire a reduction of headache intensity, duration and frequency, most of all. As mentioned above already, a number of associated variables, such as reduced self-efficacy, maladaptive social patterns, and difficulties with personal organisation and life skills in the widest sense, emerge from the comprehensive headache assessments.

The course of adjustment following a mild brain trauma often runs from an initial focus on medical management and physical recovery, followed by a “wait and see” or “it might get better on its own” period, to a stage when patients notice that their headaches have started to rule their lives and they then feel desperate for help. Just like Harry in our example, people are keen to reinitiate contact with the headache service when their own attempts to cope have been exhausted or have failed.

In the meantime, they may have found ways of achieving short-term headache relief, either using medication and by avoiding potential triggers and mental or physical activities. Such short-lived strategies do not lead to substantial and lasting improvements. If underlying mechanisms are not addressed, then a deterioration of the health condition is likely to occur, at a huge cost to the person (and the health service).

The CBT-based biopsychosocial approach to headache treatments addresses three main areas and goals:

• • headache focus: reduction of headache parameters
• • coping focus: acceptance of vulnerabilities, management of headache- related anxiety and depression, optimisation of health behaviours, improvement of coping styles
• • lifestyle and social focus: improvement of headache-related psychosocial interactions, realisation of purposeful activities and core life values.

The course of the therapeutic interaction begins with assessments and the establishment of robust and positive pain coping styles. After this, it moves swiftly to the therapeutic activities, addressing headache-maintaining, secondary psychological variables and underlying drivers and patterns that have prevented the patient from leading a satisfying and healthy life. The shift away from headache as a medical symptom towards personal life aims and values is a main theme of biopsychosocial therapy (Figure 2.4). This approach is grounded in research about chronic brain-body disorders that seem to be driven by the aforementioned allostatic imbalance. Physical activity and social interactions are, therefore, vital in achieving reductions in stress and pain.

CBT in combination with tailored creative therapeutic strategies is a method for leading patients along the journey from symptom to lifestyle management.

Headache specialists in trauma or brain injury units may come from various professional backgrounds, for example, they may be counsellors,

Figure 2.4 Shift of therapy focus throughout the course of the headache therapy.

nurses, physiotherapists, occupational therapists, doctors, psychologists, or psychotherapists. A well-coordinated package includes medication management, physio- and exercise therapy, diet programmes, pain management techniques, fatigue management, vocational and life-skills orientated rehabilitation. Headache therapists are advocates of such types of integrated health therapy, which is further shaped by the recovery from mild brain trauma.

Perhaps the majority of patients with posttraumatic headache only need to attend a one-off session at the headache clinic in order to understand and initiate the shift from focussing on the headache towards lifestyle changes.

A significant minority, however, present with long-term and complicated health and life scenarios. Some people affected in this way can be more reluctant to let go of their expectation of remaining a passive recipient of medical treatments. Patients are required to shift their belief that they have purely medical problems, which are in the domain of doctors, to an acceptance of the fact that their own health experiences and behaviours contribute to and manifest their headache condition. Eventually, they understand and participate in guided interventions that are, in fact, self-management approaches.

This belief shift requires two main components. First, it entails patients’ own psychological components, such as the stable cognitive patterns representing the personal identity. An attempt to alter such patterns, even in therapy, temporarily weakens the person’s sense of identity. The accident or injury may already have been experienced as traumatic. People talk about their “shattered self.” This is often evaluated as a threat to the integrity of the personality and people have the urge to reconstruct their former self quickly. This means that a substantial amount of courage, self-confidence and a safe therapeutic setting are needed for someone to shape their new learnings about the condition into a more dynamic identity, whilst also taking up positive and healthy behaviours.

Second, the shift of focus in therapy needs to be encouraged by a clinician who can role-model and encourage a creative way of rebuilding someone’s life. The therapist may need to be mindful of where in the “change process” the patient is and may have to utilise techniques to optimise motivation.

In practice, this means that therapy exercises, explorations of emotion and behaviour, pain and task monitoring, etc. need to be negotiated with each patient as they have to realise that they need to put in the work themselves. Reluctant patients may benefit from highly creative therapeutic methods to tap into their very personal “make-up” and to ignite the readiness for change.