Headache therapy session 4: how can I improve the quality of my life?

Useful material

Activity planner & well-being schedule Peripheral and Central Sensitisation Figure 1.6 Headache relief imagery-healing paradigm Headache relief imagery-hat anaesthesia Mind-absorbing activities worksheet My well-being actions worksheets 1 & 2 Pain Gate worksheet Positive self-talk worksheet Thinking about headaches worksheet


  • • Cognitive behavioural headache model
  • • ABC of headache management: В = behaviour
  • • Importance of physical exercise
  • • Pacing and fatigue management
  • • Habit changing strategies


“We are now in the middle of your headache programme. I wonder if you have already noticed how your attitude towards your headache is changing and how you have started to take your health into your own hands.”

Main therapy section

ABC of headache management

Use the worksheets Pain Gate and my well-being actions 1 & 2, Peripheral and Central Sensitisation Figure 1.6

Notes for therapist: The emphasis in this part of the therapy is on behaviour and habit change. The Pain Gate and Central Sensitisation theories can be adapted to explain the importance of the Action Systems for the development of alternate, health-promoting behaviours that dampen the pain processes and distract the transmission of pain signals. The suggested worksheets can be discussed to introduce and consolidate the theme of this session.

“Today you will discover a range of techniques designed to further enrich your choice of alternative activities and to distract your pain processing systems. We will practise these together. You should continue to use them in your own time and decide which ones work best for you.

“B is for Behaviour. It refers to anything we do in response to the Antecedents, i.e., the anticipated and actual headaches. Our thoughts and worries also drive our behaviours. The Pain Gate illustrates the factors that enhance the Actions Systems. The more we do, think and feel the pain, the more skilled the brain mechanisms will become in fine-tuning the pain systems.

“The idea of the Action Systems can be used to build skills in optimising alternative and well-being behaviours. If you are fully engaged in such behaviours, this means that the attention and thinking processes will prioritise your purposeful alternative over headache processing. The following strategies can help consolidate this.”

Physical exercise

Notes for therapist: Gentle physical exercise is vital for healthy heads. Muscle tension and bad postural habits can be reduced by engaging in physical activities such as Nordic Walking, Pilates, Tai Chi, aerobics and many more. Such physical activities should be carried out daily or as regularly as possible. Gentle physical exercise increases blood circulation, reduces inflammatory processes and has been shown also to improve concentration and information-processing disturbances in headache patients.

Patients are encouraged to plan their exercises and perform them, at least partially, even if they have (mild) headaches at the time. In the case of severe headaches or migraines, they should apply relaxation techniques and change the intensity and length of the activity. If headaches begin during a physical activity and the patient prefers to end the activity, it is important to remain aware of thoughts and mental self-statements at that moment. Patients should be encouraged to reward themselves for having mastered parts of the activity and for their mindful regulation of thought patterns. These are substantial achievements for a person who has not attempted to exercise or use alternative methods ever before.

Patients might want to re-engage with favourite physical activities that they enjoyed before the accident and may have stopped due to the headaches, e.g., walking, gardening, dancing or horse-riding. Other patients might always have wanted to start something new, such as sailing or going to the gym. In the case study example, Josh used his juggling skills as a mind-absorbing physical activity, which he enjoyed in the outdoors. As one can see below, exercise can also balance energy levels as daytime fatigue is addressed. Now might be the opportunity to utilise the structure and therapeutic support, which is integral to this approach in order to integrate physical exercise into daily routines.

Pacing and fatigue management

“Daytime fatigue is common with chronic headache. Concussion and psychological trauma upset the natural ebb and flow of our hormone system, which regulates energy levels, mood and performance each day. The disruption of routines, the anticipation of pain and the fear of negative - especially social - consequences, disturb the diurnal stress hormone (i.e., cortisol) levels. This means that at times of high demand, there is less cortisol available to keep the systems active or to regulate micro-inflammations. Lack of resources drain bodily systems and result in ongoing fatigue, “burn out” and possibly more headaches. This can be overcome by adopting a gentle graded approach during the recovery process.

“Changing what we do and how we approach our lifestyle can help synchronize our hormonal and biochemical rhythms and as a result we have less fatigue.

“Here are some suggestions for optimising your bio rhythm:

  • - Arrange important tasks earlier in the day
  • - Take breaks
  • - Increase natural light exposure
  • - Reduce screen time
  • - Eat regular meals and regulate your caffeine consumption
  • - Explore your sleep hygiene, wake up at the same time every day and get out of bed
  • - Be careful with hypnotic or benzodiazepine medication use.”

Mind-absorbing activities and coping

There are endless opportunities for health-focused behaviour change.

Cognitive exercises as shown below can be powerful attention diversion strategies to redirect headache worries, interrupt headache monitoring and reshape avoidance behaviour. The patient needs to practise examples of coping exercises with the therapist and at home during headache-free periods to become familiar with them. The activity planner & well-being schedule can be a helpful planning aid.

Thought-stoppinglpattern interrupting

The therapist sets the scene to mentally expose the patient to a situation when they might have headaches, or fear or worry about the headaches.

The patient is instructed to briefly pay full attention to the worry or the pain and immediately switch attention.

“I would like you to practise ‘thought-stopping.’ This is a very important strategy to have. You need to practise in headache-free times first and, when you have mastered it, it will be very effective.

This is what I would like you to do:

I want you to visualise a stop sign.

Now tell me what your stop sign image looks like.

What shape does your stop sign have?

Is it two dimensional or three dimensional?

What colours does your stop sign have?

What colour are the letters of the word ‘stop’?

What is the font - lower case or upper case?

What size is the stop sign?

Is the stop sign fixed to a post or is it hanging down from somewhere?

How close to you is the stop sign?

Does it just read ‘stop’ or does it also make a noise telling you to ‘stop’?

You have a very detailed image and powerful stop sign.

Now I would like you to imagine that we have this stop sign right here. I am pretending to hold it up for you. Is that right? Distance right? Good.

Next, I am going to ask you a question and as you are giving me the answer, I will shout ‘STOP’ and hold your imaginary stop sign out in front of you.

Now, please describe to me how you prepare your cup of coffee at home.

(Allow three to five seconds for the answer, then interrupt in the middle of the answer - this has to be done quickly, but not in a rushed manner).


Thank you. Now tell me about a previous holiday/family outing/weekend activity.


Thank you. Now, please describe your best friend/supportive family member to me. What are they like?


“Now, please tell me what happened. How did the instruction to stop interfere with your narratives? Each new question interrupted your memory and thinking about the previous one and each stop interfered with your attention to your story. From now on, I would like you to remember your stop sign as one of your most powerful tools. Initially, practise thoughtstopping during your normal day-to-day routines and headache-free periods. Make sure you gain proficiency in the use of the strategy. When you experience distressing worries or headaches, briefly pay full attention to them, then quickly say the word ‘stop!’ to yourself and visualise the stop sign in front of you. This brief moment of focused attention allows you to select another effective coping strategy that can take your mind off the headache for longer.

“Of course, it might be much easier to interrupt an emotion-neutral image (such as coffee-making or remembering a holiday) as opposed to diverting from real pain or pain-related thoughts. Therefore, your stop sign image must be convincing, strong and well-rehearsed.”

The attentive reader might notice the similarity of this thought-stopping exercise with the magic spell technique “Riddikulus!” that was helpful for

Bethan, or even Holly’s Viking warrior strategy. The “No Diet Diet” metaphor is also a “pattern interrupt” strategy.


The therapist sets the scene and prepares the patient for another exercise:

“Please tell me what you had for breakfast this morning!” ... Allow three to five seconds for the answer, interrupt in the middle of the answer; this has to be done quickly, but not in a rushed manner.

“What is the colour of your car?” ... Immediately move to the next question.

“Who is the current Prime Minister?” ... Immediately move to the next question; if the patient is slow in responding, move to the next question.

“What news event do you remember from the last few days?” ... Immediately move on.

“When did you move into your current home?”

“Thank you. You are doing very well indeed. This means that you are able to quickly switch from one thought to another. You can do this any time. You can also do this when you notice yourself worrying about your headaches or focusing on the pain. When this happens, quickly say the word ‘STOP! ,’ visualise your stop sign and switch thoughts rapidly. This is a bit like mental gymnastics, but it means that you stop rehearsing your headaches and that you detach yourself from headache-related thinking and acting.”

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