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Headaches and Brain Injury from a Biopsychosocial Perspective

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Post-traumatic headache is the most common symptom after mild/moderate brain injury. Similar to the characteristics of naturally occurring headaches, it is multi-faceted in nature and includes neurophysiological, psychological and social aspects. Consequently, headache has an enormous impact on the quality of life of the sufferer. Effective headache treatment has a focus on all aspects of the pain and the needs of the individual.This book describes a cognitive-behavioural program which was developed as part of a research project in a brain injury service. It is based, firstly, on the evidence provided by the outcomes of this research project. The interested reader may study the literature associated with this research for which the references can be found at the back of this volume. Secondly, this headache therapy guide is the result of clinical experience and the application of cognitive behavioural therapy to patients who experience complex difficulties following a brain injury.

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CHAPTER ONE Headaches and brain injury

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CHAPTER ONE

Headaches and brain injury

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linicians and researchers have long been puzzled by patients presenting with enduring problems following brain injury.

Literature on mild brain injury, post-concussion symptoms, and post traumatic headaches frequently reports the lack of symptom specificity, the controversies and complexities surrounding the existence of such problems, and the rarity of good studies helping to identify their causes and consequences. Consequently, doctors and therapists have often felt paralysed in their attempts to offer helpful treatments for headache patients.

This chapter attempts to present the available knowledge about headaches and brain injury in a structured way. By showing that an understanding of the condition and its psychological treatment is possible, despite weaknesses in medical or scientific descriptions, scaffolding for later sections of the book will be provided.

 

Chapter One - Headaches and Brain Injury

ePub

Clinicians and researchers have long been puzzled by patients presenting with enduring problems following brain injury. Literature on mild brain injury, post-concussion symptoms, and post traumatic headaches frequently reports the lack of symptom specificity, the controversies and complexities surrounding the existence of such problems, and the rarity of good studies helping to identify their causes and consequences. Consequently, doctors and therapists have often felt paralysed in their attempts to offer helpful treatments for headache patients.

This chapter attempts to present the available knowledge about headaches and brain injury in a structured way. By showing that an understanding of the condition and its psychological treatment is possible, despite weaknesses in medical or scientific descriptions, scaffolding for later sections of the book will be provided.

Brain injury or head injury?

The terms “brain injury” and “head injury” are used in the literature almost synonymously and, while they are closely related, it is useful to distinguish between them. The term “brain injury” describes a condition associated with changes within the brain, usually assumed to have been preceded by some sort of external trauma, or “head injury”.

 

Chapter Two - Biopsychosocial Approaches to Headaches Following Brain Injury

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Introduction

The following sections introduce theoretical explanations for the development and maintenance of persisting headaches. Reductionist or unidirectional perspectives on headaches after brain injury can be overcome as medical, psychological, social, and practical perspectives are combined.

The literature on headaches and post-concussion syndrome demands clarity about these conditions to enable the development of effective interventions. As not one theory alone can explain the complexity of headaches after brain injury, their integration here into a biopsychosocial approach will set the scene for the holistic assessment and therapy guide that follows.

Pain gate theory

Acute pain has an important function in signalling tissue damage to bodily systems responsible for the initiation of healing and repair. In order to achieve this, the injured area becomes hypersensitive, especially when in contact with external stimulation. This has a protective function so that further injury, or the interruption of the healing process, can be avoided.

 

CHAPTER TWO Biopsychosocial approaches to headaches following brain injury

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CHAPTER TWO

Biopsychosocial approaches to headaches following brain injury

Introduction

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he following sections introduce theoretical explanations for the development and maintenance of persisting headaches. Reductionist or unidirectional perspectives on headaches after brain injury can be overcome as medical, psychological, social, and practical perspectives are combined.

The literature on headaches and post-concussion syndrome demands clarity about these conditions to enable the development of effective interventions. As not one theory alone can explain the complexity of headaches after brain injury, their integration here into a biopsychosocial approach will set the scene for the holistic assessment and therapy guide that follows.

 

CHAPTER THREE Implementation of a practical biopsychosocial approach

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CHAPTER THREE

Implementation of a practical biopsychosocial approach

Introduction

H

olistic headache approaches must begin by asking the most important question, which concerns what patients most want from their clinicians. In Lipton and Steward’s

(1995) investigation, the majority of patients said that education about their headaches was the highest priority for them, whereas only a small number of physicians deemed this to be important (similar to

Packard’s findings, 1979). Psycho-education has proved effective in prophylaxis for persistent post-concussion problems (Mittenberg,

Canyock, Condit, & Patton, 2001). As headaches appear to be the cardinal symptom of post-concussion syndrome, it is proposed that education and reassurance should be a vital headache therapy component.

 

Chapter Three - Implementation of a Practical Biopsychosocial Approach

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Introduction

Holistic headache approaches must begin by asking the most important question, which concerns what patients most want from their clinicians. In Lipton and Steward’s (1995) investigation, the majority of patients said that education about their headaches was the highest priority for them, whereas only a small number of physicians deemed this to be important (similar to Packard’s findings, 1979). Psycho-education has proved effective in prophylaxis for persistent post-concussion problems (Mittenberg, Canyock, Condit, & Patton, 2001). As headaches appear to be the cardinal symptom of post-concussion syndrome, it is proposed that education and reassurance should be a vital headache therapy component.

In addition to the informative approach, interventions should enable patients to be actively involved in a process which should, apart from pain reduction, aim at improvement of quality of life and psychosocial functioning, as well as the long-term reduction of disability. Silverberg and Iverson (2013) emphasise the importance of a graded return to regular activity, as this prevents the development of mood disorders and chronicity of post-concussion symptoms. Graded and guided activity management maintains skills and restores mastery. These are prerequisites for confident re-participation in pre-injury roles and responsibilities. Enriched environments involving cognitive and physical stimulation also encourage neurophysiological recovery.

 

CHAPTER FOUR Cognitive–behavioural therapy guide

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CHAPTER FOUR

Cognitive–behavioural therapy guide

Introduction

T

his cognitive–behavioural therapy manual is intended as a step-by-step guide for health professionals working with headache patients. It includes a variety of assessment and therapy material that should help the busy clinician to administer an efficient and effective intervention. Headache therapy outcomes, provided in

Appendix IV, may be useful for clinical comparisons and research purposes.

The therapy philosophy is focused on lifestyle improvements and offers a range of methods for coping with pain, with the consequences of pain, and with pain-related cognitive and emotional problems.

 

Chapter Four - Cognitive–Behavioural Therapy Guide

ePub

Introduction

This cognitive–behavioural therapy manual is intended as a step-by-step guide for health professionals working with headache patients. It includes a variety of assessment and therapy material that should help the busy clinician to administer an efficient and effective intervention. Headache therapy outcomes, provided in Appendix IV, may be useful for clinical comparisons and research purposes.

The therapy philosophy is focused on lifestyle improvements and offers a range of methods for coping with pain, with the consequences of pain, and with pain-related cognitive and emotional problems.

The proposed headache programme can be delivered in the form of individual psychotherapy sessions, group interventions, or a combination of both.

Individual therapy increases the opportunities for tailoring therapeutic strategies exactly to the patient’s situation and headache experience. This increases the effectiveness of the interaction between therapist and patient. Headache therapists are invited to use the methods and material in this book creatively, provided they are consistently guided by the principles underlying the therapy: cognitive–behavioural therapy, positive psychology, and wider approaches: that is, biopsychosocial and neurological rehabilitation.

 

Chapter Five - Module 1: Headache Assessments

ePub

The practising clinician may already be very skilled in undertaking the clinical assessment of various conditions. The following sections are meant to highlight specific considerations regarding headache patients. For more generic approaches towards assessment, interested readers may refer to the relevant sections in Newby, Coetzer, Daisly, and Weatherhead (2013), another book in this series.

Assessment of headaches is aimed at achieving a better understanding of the development, maintenance and dynamics of headaches. Key questions include: “Why do headaches occur or get worse at one time rather than another?” and “Why is the patient particularly vulnerable to headaches following a brain injury?”

When assessing headache patients, it is important to bear in mind that they will have already talked about their headaches numerous times to doctors and rehabilitation workers. They may also have received rehabilitation aimed at other impairments following their brain injury. The assessment of their headache at this point should aim at understanding the patient and the meaning of their pain. The assessment module gives the patient plenty of opportunity to explore the consequences of the brain injury, the details of the headaches and contextual problems.

 

CHAPTER FIVE Module 1: headache assessments

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CHAPTER FIVE

Module 1: headache assessments

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he practising clinician may already be very skilled in undertaking the clinical assessment of various conditions. The following sections are meant to highlight specific considerations regarding headache patients. For more generic approaches towards assessment, interested readers may refer to the relevant sections in Newby,

Coetzer, Daisly, and Weatherhead (2013), another book in this series.

Assessment of headaches is aimed at achieving a better understanding of the development, maintenance and dynamics of headaches. Key questions include: “Why do headaches occur or get worse at one time rather than another?” and “Why is the patient particularly vulnerable to headaches following a brain injury?”

 

CHAPTER SIX Module 2: health management

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CHAPTER SIX

Module 2: health management

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his module is intended to gently encourage and focus participants on self-management. This part can be successfully introduced to small groups of between two and six participants. It is meant to be delivered as a health information and stress-reduction programme. The core ingredient is the relaxation practice.

Patients would benefit from having their own copy of this book (or an e-book version). Therapist and patients can together refer to the relevant theoretical sections (e.g., pain gate theory or stress models).

Content and aims

Introduction to the holistic headache programme.

 

Chapter Six - Module 2: Health Management

ePub

This module is intended to gently encourage and focus participants on self-management. This part can be successfully introduced to small groups of between two and six participants. It is meant to be delivered as a health information and stress-reduction programme. The core ingredient is the relaxation practice.

Patients would benefit from having their own copy of this book (or an e-book version). Therapist and patients can together refer to the relevant theoretical sections (e.g., pain gate theory or stress models).

Content and aims

Introduction to the holistic headache programme.

Facilitation of engagement with health self-management.

Introduction to stress management by providing health information and teaching coping skills.

Introduction to and practice of relaxation.

Introduction to health-related personal efficacy.

Exploration of responsibilities, choices, and interactions in relation to stress.

 

Chapter Seven - Module 3: Individual Headache Therapy

ePub

Therapy setting

The health management module introduces patients to the self-help philosophy, focused on personal efficacy and aimed at teaching foundational stress-reduction strategies.

The aims of the individual therapy programme are:

headache symptom reduction;

improvement in quality of life.

The health management module has given patients opportunities to experience that they can modulate their headache by regularly applying positive coping strategies. It is hoped that via the process of accepting the headache condition, healthier behaviours and beliefs may already have begun.

Patients will have observed the links between activities causing and maintaining headaches, as well as those causing avoidance and loss of confidence. The 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 their life goals and values.

 

CHAPTER SEVEN Module 3: individual headache therapy

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CHAPTER SEVEN

Module 3: individual headache therapy

Therapy setting

T

he health management module introduces patients to the selfhelp philosophy, focused on personal efficacy and aimed at teaching foundational stress-reduction strategies.

The aims of the individual therapy programme are:

headache symptom reduction; improvement in quality of life.

The health management module has given patients opportunities to experience that they can modulate their headache by regularly applying positive coping strategies. It is hoped that via the process of accepting the headache condition, healthier behaviours and beliefs may already have begun.

 

Appendix I - Therapy Worksheets

ePub

ABDOMINAL BREATHING

Abdominal breathing is achieved by expanding the abdomen rather than the chest when breathing in and releasing the abdomen when breathing out.

This type of breathing slows down your breathing rhythm, which helps when you are stressed or worried about your headaches.

Slowing down your breathing consciously can intensify your relaxation experience.

Begin by placing your hands on your abdomen.

Notice how your abdomen expands when you breathe in and how it is released when you breathe out.

If this is difficult, try it lying down.

Practice

Take a deep breath. Notice your abdomen expanding.

Let the air out slowly. Count aloud for as long as possible.

Empty your lungs.

Hold the breath for a couple of seconds.

Take in a new deep breath, expanding your abdomen.

The pain gate responds according to the extent of an injury and the readiness of the nervous system to send and process pain signals.

 

APPENDIX I Therapy worksheets

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APPENDIX I

Therapy worksheets

ABDOMINAL BREATHING

Abdominal breathing is achieved by expanding the abdomen rather than the chest when breathing in and releasing the abdomen when breathing out.

This type of breathing slows down your breathing rhythm, which helps when you are stressed or worried about your headaches.

Slowing down your breathing consciously can intensify your relaxation experience.

Begin by placing your hands on your abdomen.

Notice how your abdomen expands when you breathe in and how it is released when you breathe out.

If this is difficult, try it lying down.

Practice

 

Appendix II - Relaxation Scripts

ePub

FOCUSED BODY RELAXATION

Induction:

Just make yourself as comfortable as possible in your chair.

Notice what it feels like, having just arrived here.

And what it feels like sitting here, in this chair.

And as you notice yourself sitting here,

you can allow yourself to sink deeper into the chair,

and feel supported by the back of your chair.

That’s right. Good.

Now, most people enjoy doing this relaxation with their eyes closed, and if it is all right with you,

then just allow your eyes to close right now;

and if it’s not all right, that’s fine as well.

Then just let your eyes rest on a spot on the carpet or the wall;

and at any time, sooner or later or right now,

when they feel heavy, so very, very heavy,

just let them close.

I wonder which eye might feel heavy first.

Now, I would like you to listen to the noises outside the room.

And now listen to the noises inside the room.

 

APPENDIX II Relaxation scripts

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APPENDIX II

Relaxation scripts

FOCUSED BODY RELAXATION

Induction:

Just make yourself as comfortable as possible in your chair.

Notice what it feels like, having just arrived here.

And what it feels like sitting here, in this chair.

And as you notice yourself sitting here, you can allow yourself to sink deeper into the chair, and feel supported by the back of your chair.

That’s right. Good.

Now, most people enjoy doing this relaxation with their eyes closed, and if it is all right with you, then just allow your eyes to close right now; and if it’s not all right, that’s fine as well.

Then just let your eyes rest on a spot on the carpet or the wall; and at any time, sooner or later or right now, when they feel heavy, so very, very heavy, just let them close.

 

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