The cognitive behavioural headache formulation

Notes for therapist: The therapist will, by now, have very detailed information about the patient’s symptoms and the variables that contribute to their complexity. It is important to relate the dynamic meanings of the headache to the personalised formulation, rather than approaching the condition from a technical cognitive behavioural model only.

The patient can learn more about how the headaches, along with the critical onset event, have taken control of their lives.

The cognitive behavioural headache formulation illustrates headache components from a life history perspective, beginning at the early history through to current lifestyle. This model describes how the headaches have developed as a very individual experience and pinpoints exactly which behaviours and psychosocial variables maintain the condition. The CBT model indicates numerous exit routes out of patients’ vicious cycles and opportunities for altering their lifestyle. In negotiation with the therapist, they can select the most practical adjustments and how to go about them.

ABC of headache management: A = anticipation, adversity, adjustment

Use Headaches after mild brain trauma Figure 2.5.

Have the assessment information and the headache report at hand. Guide the patient step-by-step through the Headaches after Mild Brain Trauma figure, exploring past personal and health factors, the critical event and brain trauma and the resulting symptoms and consequences.

Discuss how cognition, behaviour, emotion and social interaction are interlinked.

Use the my headache formulation worksheet

Encourage the patient to complete the my headache formulation worksheet by relating to their personal and headache history and including examples from the assessment information.

Use the A BC of headaches and /(BC of overcoming headaches worksheets “There are other ways to illustrate the dynamics of a headache pattern. Let’s say, the headaches are such an Adversity to deal with. Due to the natural fear of pain, people use spontaneous behaviours to achieve immediate relief. The behaviours are compounded by negative beliefs associated with the headaches, resulting in thinking and worrying about them. Making an effort to Adjust, to do things differently and think appropriately, could lead to feeling all right or gaining control, behavioural Adjustments lead to healthier beliefs and to different Consequences. The headache pattern can be interrupted. The Pain Gate can close a bit.”

“What adjustments can you aim for?

  • - Behaviour: pacing, activity planning, practice of coping strategies, improvement of posture, sleep hygiene, diet, etc.
  • - Cognition: challenging worries and mental traps.
  • - Emotion: feeling safe and in control.
  • - Social: communicating genuinely, taking part a little and often.”

Emotions and feelings

Notes for therapist: Thoughts and emotions related to headaches must be explored in combination. Emotions are verbally processed and evaluated. Socratic questioning is an effective therapeutic technique to explore such associations. A patient whose initial thought at the beginning of the headache episode may be, “Oh no I can’t cope with this!” or “A headache in the morning means 1 am going to have a very bad day at work,” can be asked the following questions:

“What do you mean by coping and what would it be like if you knew how you could cope?

What exactly is it that you cannot cope with?

What would be so bad if you continue not coping?

What is the worst that could happen?

What would be so bad if the worst did happen?”

Explorations of this kind address core anxieties, which can become a matter of further therapeutic attention. Patients may benefit from information about core primary fears associated with anticipated pain and the traumatic event, and secondary feelings about the headache condition as a whole. Feelings are the results of emotional evaluations of the complex and chronic circumstances in which the patients find themselves. Giving patients space in the therapeutic contexts to express and process headache-related feelings can optimise their emotional resilience.

Headache coping strategies Therapeutic language tips:

Exploration of emotional experiences and encouragements of alternative activities benefit from using the word “howe.g., “How have you modulated your headache worries?” The word “how” implies that the patient has reflected on this already. It is an encouraging phrase.

In the case of negative responses, such as, “I have not reflected on it,” or “I don’t think that this would work for me,” the therapist can respond, “That’s right, you haven’t... yet. In the meantime, I want you to pretend that your experience has changed. Using your imagination, just pretend to change your spontaneous mental self-talk. What happens? Let’s pretend changing your belief of T can’t cope with my daily responsibilities’ to T am aware of my head sensations now. I can direct my attention to my breathing pattern. This will help me whilst I am reading a story to my daughter for another ten minutes.’”

Alternative activities

"The No Diet Diet” metaphor:

Psychologists have researched the effect of diverting attention away from a problem. For example, a weight loss programme “The No Diet Diet” encourages people who aim to lose weight by trying different things every day. The activities are not at all related to losing weight. This is a “pattern interrupt” technique, i.e., unhealthy behaviours are replaced by neutral or healthy ones. For example, people are encouraged to buy a different newspaper than their usual one, to drink a different type of beverage, to get up earlier, use a different bus route, wear something different, etc. It was discovered that those people who changed their habits also lost weight, not as much as dieters, but they did maintain their weight loss. Importantly, the no-dieters began to make healthier and wiser choices in many other areas of their lives. It’s all about behaviour change and adopting an alternative proactive approach. People find habit changes challenging. There may be obstacles to face in relation to past problems and to circumstances related to the brain trauma and headaches. People may want to wait until certain problems are sorted (children start school, they have more money, better housing, have repaired the car, etc.), but life will always be complicated and the management of daily hassles needs to be incorporated.

The “No Diet” analogy can be implemented in the headache programme to facilitate any first steps in approaching habit change. Patients are encouraged to choose one or two small activities per week and consistently focus on breaking unhelpful habits and implementing “pattern interrupts.”


Notes for therapist: Desensitisation is a useful classic therapeutic approach. The patient has probably experienced a challenging event and the headache might represent relived psychological trauma. Exposure to inappropriate headache-related worries or beliefs while in a safe environment and a comfortable physical state leads to desensitisation of the stress symptoms generated by such negative thoughts. The patient identifies strategies (relaxation, grounding techniques, ideal environment) that stabilise confidence.

Desensitisation Practice:

“Let’s say you want to feel less stressed when you notice your intrusive headache-related worries. Most worries are irrational exaggerations of consequence that are unlikely to happen. Your thinking brain needs to realise that the body’s alarm systems have malfunctioned. They need to get ‘bored’ of unnecessary states of alert. Here is how you can learn to get bored of distressing worries.

“Combine this exercise with relaxation and practice by using emotion-neutral thoughts initially. Get comfortable, ground yourself and settle into your usual relaxation routine. When you are fully relaxed in the way you are used to, just allow your mind to welcome all sorts of thoughts and ideas. Just let them float through your mind without interfering with them. Like a bystander, passively observe them.

“Now, imagine a big cinema screen and, using a spray can, write the thought down that enters your mind first. Spell out the letters of your thought with your spray. Notice the writing and the colour of the paint. And as you are focusing intensely on the big screen, you become aware how the letters blur and begin to dissolve. The more you look, the more they disappear and fade away. As you strain your eyes, they become dry and the words fade even more. Notice how this happens and let the words fade away completely. Notice how you can make thoughts easily disappear, just like that. Notice the blank screen and slow down breathing... Notice how your body is so very relaxed...

“Now repeat this with the next thought that comes to mind, even if it is the same one. Spray the sentence down. Notice the writing, the letters, the spelling, and read the sentence over and over again while continuing to breathe and remaining relaxed. Notice how the words begin to disappear, they just don’t stick, they just fade away, they disappear from your mind, again.

... Repeat ten times...

... You are relaxed...

“And as you are repeating this exercise over and over again, you realise how boring this becomes; you can no longer hold on to the thought, your mind just wants to let go.

“Notice how easy it is to get bored with redundant thoughts, how easy it is to let them drift past your mind, passively.

“You know now that you can do this any time, whenever and wherever thoughts and worries recur, you know how they will just want to fade away...”

It is recommended to elicit examples of disturbing or distressing thoughts in the therapy session. The patient can use their worksheets to choose and list such examples. With the help of the therapist, the distressing thoughts or images can be ranked. When the patient is skilled in applying an exercise like the one above with neutral thoughts, they can progress through their list of negative and distressing ones.


“Today you have explored how the headaches with all their components have become part of your life. You have explored a number of strategies for adjusting your routines and habitual patterns. Remember to use the activity planner & well-being schedule or the my well-being actions 2 worksheet to practise your strategies and your relaxation.”

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