Module 2: headache clinics for people with mild brain trauma

What do headache patients want from their doctor? According to research, the answer is not just medical treatment, as one would expect, at least not in the long term. What patients really want from their doctors is an understanding of their pain.

Nevertheless, a physical examination by a medical specialist is vital at the outset, first, to check that no underlying medical issues that require immediate attention (such as haemorrhages or tumours) are present and, second, to identify the specific subtype of posttraumatic headache, upon which a subsequent formulation and therapeutic approach may be based. After such medical reassurance and clear diagnosis, patients will be much more likely to engage with therapists in an exploration of non-medical and alternative factors that constitute their headaches.

Psychologically informed early intervention for people with mild brain trauma is highly recommended and this includes prevention of persistent posttraumatic headaches. This is because people with psychosocial predispositions and complications are most at risk of developing posttraumatic headaches and secondary problems that potentially maintain and reinforce their conditions.

Specialist clinics for people with mild brain trauma symptoms, predominantly headaches, apply a manualised and tailored approach to guide both the specialist and the patient through the clinical encounter. Such headache clinics aim to facilitate the shift from the medical and symptom-focused understanding to the comprehensive biopsychosocial philosophy. This sets the pace for the engagement with headache management and initiation of proactive lifestyle changes.

The key aims of such one-off sessions include:

  • • Engagement, reassurance and normalisation
  • • Psycho-medical education and reformulation
  • • Motivation for ongoing self- and health management.

Patients are usually referred to the specialist brain trauma or pain clinic by their family doctor. Commonly, following an accident, people check in at hospital emergency services, where they see medical specialists and undergo tests and scans to rule out a more serious brain or neurological injury. Such medical investigations are vital, but patients are often puzzled about the conclusion that there is apparently nothing wrong with them. Some people are told that because their scans were clear or that, because they did not lose consciousness, their brains are fine. Whilst patients are certainly relieved about such news, such medical reassurance does not always eradicate their headaches. Head trauma clinics based on the psychosocial and early intervention approach offer the opportunity to explore their questions and uncertainties.

In a review of patients who found themselves waiting for a specialist headache clinic session, many reported not having dared to leave the house in the early stages following a trauma event due to the severity of the headaches they were experiencing. They impatiently awaited their appointment as they did not know how to help themselves, whilst the pressures to either return to work or to carry on with their roles in their family continued to mount.

Patients with complex mild brain trauma problems, including headaches, most benefit from the reformulation of their experience in the light of their critical life events, underlying anxiety and stresses. The clinic’s success may be found in patients’ decisions to take their lives into their own hands by participating in headache therapy or generic cognitive behavioural therapy.

Patients who predominantly experience headaches as their mild brain trauma symptom seem to get the most out of the one-off specialist clinic. The skilful combination of validation, reassurance and education about pacing and proactive lifestyle changes has been shown to optimise posttrau- matic headache patients’ coping repertoire.

According to the aforementioned research, the single clinic session can offer long-term prevention of secondary problems or prolonged unnecessary medical and therapeutic involvement.

This also means that the clinic setting must offer a close-to-ideal milieu so that patients can make the most of this opportunity. A welcoming environment is, therefore, just as important as the empathetic and attentive manner of the health professional.

The clinic for people with posttraumatic headaches follows the same structure as the full-length headache therapy introduced here.

First, attention is given to assessment and assessment outcomes.

Second, rapport building and patient engagement are the key elements to guide the person towards behaviour change.

Third, the major part of the session focuses on the reformulation and shift away from the fear about organic lesions towards an understanding of the biopsychosocial interplay of all their personal and social factors, with a particular focus on stress factors and long-term demands.

Finally, patients are encouraged to explore their emerging ideas about the changes they can make in order to reduce their headaches and their stresses and to improve their health and lifestyle.

Engagement and assessment

The first step is nevertheless symptom-focused. It is important to meet the patient at their present point in time. Patients may come prepared with their headache diaries and questionnaires, which perhaps were sent in the post along with the appointment details. They may be required to briefly reiterate what originally had happened to them and how they are affected by their headaches. In contrast to their initial visit at the doctor’s, they will be guided to tell their story slightly differently this time. Active listening and careful attention to the elements related to their past history, personal and social factors, as well as to their coping attempts, shape the story in such a way that the underlying, less obvious, but still crucial predispositions and concurrent complications will surely come to light.

This is the time for rapport building; assessments of types of symptoms, their frequency and intensity; a discussion of the medical findings and an exploration of the physiological theories. The examples of Alice, Harry or Anthony come to mind here.

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