Headaches after mild brain trauma: from repair to self-care

Birgit Gurr is a consultant clinical neuropsychologist who works as the clinical lead for the Acquired Brain Injury and Adult Neuropsychology Services in Dorset HealthCare University NHS Foundation Trust, UK. Here, she explains the need for the new second edition of her book ‘Headaches and Mild Brain Trauma’.

During the course of my career, I have developed a special interest in the complex and long-term problems experienced by some people with a relatively minor brain injury. The publication of the second edition of my book Headaches and Mild Brain Trauma (with forewords by Barbara Wilson and Nathan Zasler) represents the culmination of everything I have learnt in this field over 20+ years of clinical practice, research, teaching and collaborative studies with clinical psychology trainees.

Clinicians and researchers have long been puzzled by patients presenting enduring problems following a mild traumatic brain injury. Despite advances in clinical practice, the literature on mild brain injury, post-concussion symptoms and posttraumatic headaches continues to report the lack of symptom specificity, the controversies and complexities surrounding the existence of such problems, and the rarity of good studies that help identify their causes and consequences. 

My book describes the biopsychosocial nature of persisting and complex headache presentations following a mild brain trauma, and it offers a predominantly cognitive behavioural therapy programme to guide patients toward better health and less pain. 

Placing physical symptoms of head trauma in context with personal and social issues, I discuss the broader psychological implications after brain injury, including the idea that headaches play a functional role for the patient. It’s about how patients explore their past (i.e. long before the brain trauma event) physiological vulnerabilities, either genetic, developmental or acquired ones, in addition to their personal style (e.g. endurance driven or avoidant). Importantly, they discover how these factors have contributed to cortically manifested skills (also called Central Sensitisation) which maintained their headaches. They learn to understand how their headache is pieced together with brain systems and with their behaviours in the context of their lifestyle.

The book is written with the busy clinician in mind, offering guidelines, practitioner worksheets and relaxation scripts; an all-inclusive manual for therapists setting up their own programmes. A wide range of rehabilitation professionals ­– including psychologists, psychotherapists, counsellors, psychology and therapy assistants, occupational therapists, physiotherapists, neuropsychologists, doctors, specialist nurses, and students of all related health disciplines – take it upon themselves to ease the pain of brain trauma survivors and to show them a better way to cope and re-evaluate their lives.

Great advances continue to be made within research and clinical practice to shift from a predominantly medical approach towards a greater integration of patients’ life-long experiences. These past health and personal histories combined with the acute accident factors are vital for our understanding of complex and chronic conditions such as headaches. The way a person adapts to the aftermath of a traumatic event which has affected their head and resulted in chronic pain depends on many factors about their health, wellbeing and lifestyle, both before and after the onset event. 

A case excerpt: Juggling Josh

A juggler needs to be fully engaged in the activity for it to work. Attention, sensory and motor processing as well as performance monitoring are coordinated and fine-tuned. The activity fully absorbs large cognitive networks and needs to be synchronised with body awareness and breathing rhythm. It seems that the juggler’s brain has no capacity for processing any competing stimuli, like head pain, simultaneously with the complicated flow of movements.

Josh had acquired his brain injury six years previously due to an assault and suffered with chronic headaches ever since. As part of the brain injury rehabilitation, he had been offered a shop-fitting apprenticeship, which he was about to complete when he participated in the headache programme. He said that he was very grateful for the opportunity to gain qualifications in a field he really liked; however, the woodwork areas were busy and noisy. Josh found it very hard to cope with his headaches in such an environment.

Prior to his brain injury, Josh had been homeless and had earned some money by juggling and street entertaining. His juggling skills became his most used headache coping strategy. He arranged a personalised schedule at work. Instead of having a long lunch break, he took a number of smaller breaks. During each of these, he went to the yard behind the workshops with his juggling clubs. Initially, the physical exercise component increased his circulation and helped with the release of muscle tension. The focused attention diverted him from worrying about his headaches. His improved cognitive and motor flexibility contributed to his ability to quickly switch between work tasks and coping strategies. Josh said that he would recommend juggling to all headache patients. 

A life story approach

My book explains how a life story approach enables health professionals to be open-minded about the wide range of their patients’ personal experiences.

We need to help to engage patients in exploring and reframing the many contributing facets of their condition stemming from their past experiences, their health behaviours and their beliefs about how to overcome the trauma and headaches associated with an accident. Ultimately, connecting a person’s past with the accident and resulting head pain must lead towards substantial changes in how they care for their body and approach their own health management. 

Along the way, I provide research-based explanations about the neurophysiological and biopsychological mechanisms which are active within the body as a result of acute and persistent accident-related problems. These explanations can then be used to establish a shared understanding of the condition between the clinician and the patient which will become the starting point for therapeutic and proactive lifestyle changes. I also suggest numerous creative CBT strategies in the therapy guide to engage patients and help shift them away from a passive medical to an active health-management perspective.  

Many of the therapeutic techniques can also be used with patients who experience headaches due to primary injuries to the head only, idiopathic headache conditions, or more generic postconcussion symptoms. Furthermore, the therapy plans and therapeutic methods (e.g., the health management module or relaxation therapies), as well as the practical worksheets, have the potential to be adapted for patients presenting with other complex, functional/medically-unexplained or psychosomatic complaints (e.g., chronic fatigue). 

Overall, I was keen to emphasise that a combined medical and interdisciplinary approach can encourage the shift from medical repair to motivated and proactive self-care.

 

Available from Routledge in paperback, hardback and eBook.

Headaches and Mild Brain Trauma: A Practical Therapy Guide - 2nd Editi (routledge.com)

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