Psycho-medical education, reformulation and reassurance

Although everyone benefits from clarification, it does not mean that explaining everything is useful for everyone.

The psycho-medical explanations include sharing the understanding of:

• - the medical investigations, tests and scan results or the lack of any findings
• - the reasons why they were given a preliminary diagnosis of concussion and posttraumatic symptoms
• - the psychologically relevant headache variables obtained via questionnaires and headache interview
• - the way the patient’s posttraumatic headaches fit with the Pain Gate, integrated neuro-behavioural, neuropsychological or other formulation models (see Chapter 1)
• - the neuropsychological and information-processing disturbances and how they are triggered and set off by autonomic arousal and maintained by longer-lasting stress mechanisms and
• - most importantly, the Central Sensitisation dynamics.

Appendix III includes a guide for patients with mild brain trauma who also experience headache symptoms. This useful tool enables the clinician to lead the patient through all the information explored in the session.

In a one-off clinic session it is vital to match the explanation model with the individual’s assessment outcomes and a w'ell-chosen formulation model. Explanations and reassurance are really well accepted by patients if they are close to their personal experience, lifestyle and individual concept about their circumstances.

Motivation for ongoing self- and health management

The skilled practitioner will be aware that the more a patient’s details are tailored to their formulation, the easier it is for them to relate how their headaches have become part of their health and life story. Such insights will provide the most optimal grounding for thinking about and planning healthy lifestyle changes.

Resilience is a concept that can facilitate acceptance and motivation for adaptations to daily routines. The belief that the person might have been coping with a lot more prior to the head trauma is one that a lot of people struggle with. This is often related to the person’s expectations of themselves and the amount of pressure they put on themselves to recover quickly. The metaphor of having “too much on your plate” can help patients visualise that, following a trauma event, their plate has “shrunk.” As a result, people naturally become overwhelmed more quickly. Such visualisations of the many different contributing factors to the headache condition can help identify either which things can be taken off their plate or w'hat can be done to make their plate bigger again.

Once a shared understanding about the factors that maintain the headaches has been established, one can explore strategies for exiting vicious cycles and life traps. Some of these are more straightforward, for example, referring the patient on to a vocational rehabilitation service if there are difficulties getting back to work, to physiotherapy if there are neck tension and posture problems or to community health centres if pacing, fatigue, diet or smoking are the key contributors.

Self-management strategies such as memory techniques, basic pacing strategies throughout their daily routines or simply acknowledging when they have “too much on their plate” can be enough for most people to achieve a gradual symptom reduction. Nevertheless, for a few, the idea of self-management can be an alien concept. At such a point one has to go back to the formulation models and focus on how “everything is connected” before motivating lifestyle changes and the use of strategies.

People understand that resting and relaxing are useful. However, the practice of focused relaxation exercises is difficult to justify for some and others might find it “hippyish.” Relaxation practice can be introduced as an attention strategy in line with the information-processing headache models. The person can be encouraged to use meta-strategies and ask themselves, “Where is my focus?” This brings the attention to their present moment and raises awareness of the activated stress and pain pathways as, for example, described in the Central Sensitisation model. If people are caught up in self-critical thoughts and unhelpful patterns, then such concepts can help with the realisation of their complicated circumstances and self-help strategies aimed at directing attention to what is required at a particular moment in time.

People may actually feel exhausted after 60-90 minutes of focused participation in the headache clinic. In line with the message of the session, they will benefit from a reminder that an exacerbation of headache symptoms is possible after such a focused period. Consequently, they are encouraged to take a good quality rest after the session, perhaps even before they set off for their journey home.

Usually by the end of the headache clinic, people are grateful for the comprehensive explanations and will have planned how to apply selfmanagement strategies, how to find support if their motivation fades and where to go if there are other difficulties that may get in the way of making the necessary readjustments. Some people with substantial pre-morbid vulnerabilities will require more than the one-off reformulation session and will no doubt benefit from participation in the health management and cognitive behavioural headache therapy modules.