Module 3: health management

This module is intended as a gentle introduction to self-management with a focus on relaxation practice. Health management can be successfully delivered to small groups of between two and six participants, as well as in one-to-one sessions.

The purpose and aims are:

• • Introduction to the biopsychosocial headache programme
• • Engagement with self-management of headaches
• • Provision of health information and practice of coping strategies
• • Relaxation practice.

The supplementary material includes a number of worksheets that are intended to guide the patients through the programme and to summarise the sessions. The contents will be meaningful for patients if they can reflect on it as part of the therapeutic explorations. Some patients require help understand certain terms, e.g., “locus of control” or “cognitive.” Worksheets should not be given to patients as “homework” if the content has not been a matter of discussion during the session.

Relaxation os therapy

A core principle of the positive psychology concept is the shift towards enhancement of the quality of life in headache-free periods. Disconnecting conditioned anticipatory headache fears and worries via deep relaxation can reset the body’s self-regulation processes.

Relaxation therapy aims to reduce the physiological stress that either triggers or maintains posttraumatic headaches and provides the patient with a tool to soften the pain in acute headache episodes.

Patients report an increased sense of control and reduced helplessness. Relaxation is something that they can do independently.

Relaxation therapy uses clear instructions and imagery in line with theory of learning and memory.

Relaxation therapy can:

• • Reduce muscle tension
• • Reduce anticipatory fear of pain
• • Reduce the arousal resulting from pain and anxiety
• • Increase the intensity of pain relief imagery
• • Increase information-processing and attention
• • Reduce distractibility
• • Disconnect headache sensations from irrational fears about consequences
• • Disconnect headache sensations from intrusive memories about the injury or accident
• • Achieve peripheral and central desensitisation.

Practical considerations for learning and teaching

relaxation

Learning relaxation means acquiring a new skill.

The following points are useful to consider in the early learning phase:

• • regular practice is required, which can take some time
• • begin with learning relaxation in headache-free periods
• • choose an optimal place, with no distractions and enough time
• • with advanced skill, practice can take place anywhere in any position
• • with proficient skill, relaxation can be applied to reduce stress or head tension
• • the difference between deep focused relaxation and “chilling out”
• • how individual means of relaxing can be converted into intensive relaxation techniques by increasing self-awareness (e.g., mindful breathing and walking)
• • how individual daily means of relaxing can be incorporated into personalised relaxation scripts (e.g., sense of comfort when stroking a cat)
• • proceed with a staged approach: longer and detailed induction scripts in the early learning phase; advanced skill acquisition inductions can be chunked and therapy scripts can follow swiftly.

Relaxation is best administered:

• • by the therapist in person
• • a couple of times or more during therapy sessions
• • by including the headache characteristics and preferences of the patient
• • by matching administration tempo with the patient’s breathing rhythm
• • by including tailored self-instructions, patients’ choice of wording, images and descriptions of positive experiences
• • by modulating situational components (e.g., patient in discomfort or coughing, external distractions)
• • by accommodating memory or attention difficulties in the instructions (e.g., more repetition, shorter pauses, shorter script)
• • by accepting reluctant and sceptical points of view by suggesting that patients “pretend” to relax at first, e.g., follow the instructions and “pretend to slow down the breathing rhythm”
• • by challenging a “keep busy” attitude to mask chronic pain with the experience that relaxation is safe and headaches are manageable
• • by using positive reinforcement when patients report relief of tension and pain even if only briefly or only during relaxation exercises. This still represents progress, as they did not have such relief before they practised relaxation - they have acquired a powerful skill to modulate their tension and pain; and they have evidence that they suffer from tension and not from a brain disorder
• • by increasing flexibility: relaxation scripts are adjusted to patients’ responses (e.g., breathing rhythm, time needed to enter deep relaxation phase)
• • by using intense rapport and an empathetic relationship to enhance the sense of well-being and headache relief.

Purpose of patients’ relaxation practice between sessions at home using recorded scripts:

• • to familiarise themselves with the recording prior to practice; to be aware of length, content, sound of voice, background sounds of the audio script, etc.
• • to use a pre-recorded script with their therapist’s voice, if preferred.

Relaxation exercises are most effective if the scripts (Appendix II) are tailored to the specific patient’s headache needs as well as to their attention ability and personal routines.

Relaxation exercises can be built by combining scripts in the following way:

• • Relaxation induction
• • Therapeutic component
• • Ending

The focused body relaxation, progressive muscle relaxation or autogenic training methods are ideal induction scripts for achieving a deep level of physical relaxation. It is advisable to choose one of these relaxation methods and use it consistently during the course of the headache programme. The complete script needs to be administered, followed by an ending script. When patients have gained proficiency in their practice, the induction is followed by a therapy script and then by an ending. Eventually, patients should be able to enter the deep relaxation phase very quickly. At this stage, it might no longer be necessary to administer the full induction. For example, the focused body relaxation might then only need to be administered up to the point where the patient has settled into the exercise. This point is indicated in the text of the script and in the therapy manual with the following symbol: *. The selected therapy scripts can be administered immediately following this symbol.

Patients who have counter-productive self-beliefs - i.e., do not feel worthy of taking a rest, experience guilt and see relaxation as a waste of time, as well as patients with an endurance-type coping style - may feel challenged as they want to work as hard as possible to get better or may be mentally overactive, with a solution-seeking approach. These people need to address such core patterns as part of the individual cognitive therapy, perhaps including a schema-focused approach.