Module 4: individual headache therapy
The key aims of the individual therapy programme are the improvement of health-functioning and the reduction of the headaches and associated symptoms, with a focus on an overall improvement of the quality of life.
The health management module introduced patients to the self-help philosophy, focused on personal efficacy and aimed at teaching foundational stress-reduction strategies.
This has given patients opportunities to experience modulating their headache condition by regularly applying positive and proactive coping strategies. It is hoped that healthier behaviours and beliefs may already have been strengthened as the headaches are better understood within the context of their lives. Patients will have observed the links between activities causing and maintaining headaches, as well as those causing avoidance and loss of confidence.
Individual psychological headache therapy aims to build on those insights and offer patients wider options for overcoming their health traps. In this sense, the therapy is intended to enhance their sense of self, their social interactions and responsibilities and to lead them towards proactive life goals and values.
Such aims are inherent to most psychotherapy approaches. The individual headache therapy module implements and tailors common cognitive behavioural methods to help headache patients achieve the above stated outcomes.
It is important to set the scene for therapeutic work. The therapist must ensure that the patients’ motivation to help themselves is optimised. Genuine trust and an empathetic therapeutic relationship are vital to reduce tension in the session and to promote self-healing. The therapeutic environment is crucial for headache management. This includes attention to the light in the room (e.g., neon strips, flickering blinds, etc.), the temperature, smells (e.g., carpet or cleaning fluids), sounds (inside and outside the office) and clutter (e.g., busy walls and information boards). Some services have limited influence over their environments, but there is always something each therapist can do to help their patients feel welcome, relaxed and able to concentrate.
Patients should be asked when they last had something to eat or drink and could be offered a hot drink or a glass of water. It might be useful to ascertain how much coffee, nicotine, alcohol, medication or other drugs they consumed before the session.
As mentioned in the earlier chapters, patients with post-concussion syndrome may present diffuse cognitive difficulties or might have a headache during the session. Some patients might have travelled a long distance to the clinic or attend sessions either before or after work. They might have had to cope with traffic or finding a car park, or might have waited for some time in a crowded waiting area. These events could have undermined their ability to fully participate in their therapy session.
Headache therapy follows a structured schedule that requires the patient to be engaged and attentive. If they find the sessions demanding, they could be advised to routinely practise the relaxation, as in the health management module, immediately after their return home.
The programme contains a number of exercises and practices to be carried out between sessions. The frequency of therapy sessions depends on a patient’s engagement, need for encouragement and independence with the implementation of such exercises, as well as the opportunities available for practice. Patients benefit from as much practice as possible during the programme; therefore, fortnightly sessions might be very effective. Other patients require more cognitive or motivational support. Weekly sessions might be better for these people.
Therapists are encouraged to adapt the exercises to the patient’s level of participation. For instance, sessions 4 and 5 contain a range of therapy activities. Some patients may benefit from intensive exploration of selected therapy tasks, whereas others may benefit from several different examples.
Progress assessment: Depending on the therapy design and time frame, it may be advisable to repeat assessment measures following the health management module and prior to individual therapy. The selection of measures needs to be consistent throughout the therapy and follow-up.
Session 1: I have had mild brain trauma.
Session 2: Why do I have a headache?
Session 3: Coping with headaches.
Session 4: How can 1 improve the quality of my life?
Session 5: Meaning and purpose.
Session 6: Relax!
Session 7: The world around me.
Session 8: Using what I have learnt in the future.
Session 9: Nice to see you again.
Headache therapy session I: I have had mild brain trauma
Activity planner & well-being schedule Effect of stress on the body worksheets 1 & 2 Headache diary
Meta-strategy PROM from health management module, session 4
Mild brain trauma worksheet
Pain Gate worksheet and pain pathways Figure 1.5.
- • Rationale for the headache therapy
- • Understanding mild brain trauma in the context of physiological stress mechanisms
- • Impact of symptoms on functioning and well-being
- • Activity planning
- • Headache monitoring
Main therapy section
Impact of symptoms on functioning and well-being
“In today’s session you have the opportunity to explore:
How mild brain trauma is related to a chronic state of stress.
How headaches and other mild brain trauma symptoms impact on your activities of daily living.
How you can focus on coping skills practice and ways of moving towards a more proactive lifestyle.”
“First, you might want to ask yourself:
‘How have my headaches or other mild brain trauma symptoms impacted on my routines and activities?’
‘What has changed since my assessment appointment and my participation in the health management module?”’
Understanding mild brain trauma in the context of physiological stress mechanisms
Use the effect of stress on the body 1 & 2, mild brain trauma and Pain Gate worksheets, and pain pathways Figure 1.5.
Notes for therapist: Using the patient’s understanding and language, the therapist can proceed to explain the changes in stress regulation and information-processing in the case of headaches following brain injury.
Explanation using a common understanding as below can be helpful.
“You experienced a mild trauma to your brain. That means you sustained a sudden unforeseeable impact on your head, which was registered by your brain’s alarm system as potentially seriously harming your health. Your ‘thinking brain’ encoded this as a failure to notice a threat and has now prepared your bodily systems in such a way to prevent any danger in the future. Therefore, the trauma event is securely encoded in your memory. Your attentional alertness and the sensitivity of your senses are permanently heightened.
“At the same time, your head sustained a physical impact, possibly causing bruises within the muscular-skeletal structures in your neck and head. This means that pain receptors keep firing and also activate your awareness.
“To some degree, your brain might have been thrown around inside your skull, causing micro-bruising of brain tissue or shearing of the axons of nerves cells. Such disturbances change the way the nerve cells and fibres function. Nerve cells communicate with each other using chemical-electrical methods. Often after a concussion, the transmission of signals slows down or does not work properly for a short while.
“Apart from difficulties with some of your brain functions (e.g., concentration) you might have sensed changes in the way your body processes stress. The sympathetic-adrenomedullary system (SAM), which is part of the autonomic nervous system, activates the body in the case of a real or imagined threat. It works like an emergency or alarm system, supplying resources quickly so that the body can cope with an extreme situation. The worksheet illustrates how the adrenal glands release adrenalin and noradrenalin, which optimise all functions, ready for a fight or flight.
“You probably notice this hyperactivation in the form of raised stress, including symptoms such as increased heart rate and breathing rhythm, muscle tension, sweating, restlessness, sleep problems, butterflies in your stomach and so on. Some people experience intolerance to noise and struggle in complex environments, for instance, when many people come together or in busy public places.
“The SAM has been activated at the time of your head trauma event and has now become hypersensitive. It is also called the ‘fight or flight’ response, meaning that, in the presence of danger, one either attempts to escape from it or to fight it. The SAM also supplies the emotional and physical energy to ensure we have the strength to run or fight.
“The activation of the alarm system is designed to respond to stimuli that are present in the moment. Thoughts, memories or worries about the traumatic event or about the painful experience of headache episodes are also ‘in the moment.’ These memories and images have linked or conditioned the trauma with the pain pathways. Therefore, the SAM can be triggered even if you are not directly exposed to a critical event.
“What is important here is that your trauma onset event was in the past. The recent situations that trigger your arousal, distress or pain do not constitute a real threat. It is merely the mental images linked with complex attention and information-processing functions that have been conditioned to the perception of danger.
“The discrepancy between the conditioned hyper-stimulation and the absence of an external threat can cause confusion. This is called ‘cognitive dissonance.’ This conditioned stress response indicates danger, but nothing is there to see or hear. To resolve the cognitive dissonance, your sensory systems (e.g., eyes, ears, taste, touch, muscle sensation, etc.) focus on and absorb even more stimuli to ensure nothing is missed. Hence, the former filter function of our attention systems is deactivated. All additional sensory information needs to be analysed by the respective brain regions to make sense of it.
“People feel overwhelmed by such information-overload, especially if the short-term neural information-processing functions are slowed down due to the micro-changes of neurophysiological structures.
“Cognitive dissonance also increases arousal. This feels like emotional irritability, which may lead to anger (fight response) or fear of overwhelming situations, which can raise muscle tension. Such muscle tension and postural changes may set off over-sensitive pain fibres, etc.
“There are several vicious cycles overlapping and escalating, which maintain the trauma experience and symptoms. The SAM cannot supply the resources necessary to maintain this bodily activation for very long. Therefore, a second level of stress system helps out. This is called the Hypothalamic- Pituitary-Adrenal axis (HPA-axis). It uses longer-working stress hormones, also released from the adrenal gland, in order to strengthen the body to cope with the demand. In contrast to the SAM where the physiological balance is quickly restored after a perceived threat, HPA-axis mechanisms carry on for much longer (days, weeks, months, even years) and can eventually lead to structural changes of bodily systems (e.g., heart, muscle functioning, metabolism and digestion). Whilst this is adaptive for ongoing high demand, it may lead to symptoms (e.g., chronic tension, migraines) or lasting unhealthy changes in the body (e.g., high blood pressure, stomach ulcers, inflammations) in cases when conditioned stress responses to a past event have become overreactive.
“In summary, these symptoms are the result of a maladaptive hyperactivation and are not signs of brain injury. They are uncomfortable, and cause tension and a range of symptoms including your headaches.
“Let’s look at the effect of stress on the body and the mild brain trauma worksheets to summarise how your trauma event and ongoing headaches are related and affect your overall well-being.”
Rationale for therapy
“One therapy aim is to reverse hypervigilance and reduce bodily stress. You get the opportunity to learn more cognitive and physical coping skills that help dampen the overactive alarm system. Your body and brain systems need to relearn that you are safe, that vigilance can be reduced and that the attention filter can be reset to normal again.”
“Lots and lots of practice of active coping strategies, adjustments to your routines and pacing are important approaches to help with this. This lightens cognitive effort, reduces fatigue and improves information-processing. The threshold for stress experiences moves up.”