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-This is Jack.
For the past several years,
Jack has been experiencing severe head pain
with sensitivity to light and sound.
He has difficulty sleeping
and often feels nauseated and irritable.
The symptoms bother Jack.
He went to his local VA hospital to understand what was
causing these problems and to receive care for them.
After a full workup,
Jack was diagnosed with migraine.
Over the years,
Jack has tried various types of medication for his migraine,
but he still did not get the relief he was hoping for.
He continued to miss out on social events,
had to call in sick for work,
and stopped doing the things he loved.
His head pain and symptoms were interfering
with every part of his life.
Headache disorders can be complex
and go well beyond just having head pain.
Veterans with headache disorders may experience various physical,
emotional, and memory symptoms that need to be attended to.
Veterans with migraine, tension-type headache,
post-traumatic headache, and other headache disorders
can benefit from receiving behavioral treatments
for headache.
This may include those veterans who experience difficulties
coping with or managing their symptoms,
find their symptoms getting in the way of life
despite their medical treatment,
struggle with taking medications as prescribed,
have a poor tolerance, medical contraindications
or inadequate response to drug treatment,
are pregnant, planning on becoming pregnant, or lactating,
or simply have a preference
for non-pharmacological intervention.
Jack's provider wanted him to meet with a health psychologist,
a doctor who has specialized training
in providing behavioral treatments
to help veterans with headache disorders.
-Jack, I would like to refer you
to one of our health psychologists.
They can offer short-term behavioral treatment
to help with your head pain and symptoms.
As you know, headache disorders are complex.
So I want us to be working on all aspects
of living with migraine.
Oftentimes, we need to think about treatments
that aren't only medications in order to best help someone.
So let me assure you that I absolutely believe
your pain is real
and that your experience is just as you have shared with me.
The doctor will work with you on various skills
that can help you manage and prevent your migraine symptoms,
enhance the medications you're already using,
and improve your quality of life.
These might include cognitive behavioral therapy,
relaxation strategies, biofeedback,
problem solving and coping skills,
stress-management techniques,
and acceptance and commitment therapy.
Would it be okay with you to meet with a doctor
who sees veterans like yourself with headache disorders?
-I'm not completely convinced that would help me.
Can you tell me more?
-Jack and his doctor talked about how the mind
and body impact each other in subtle and important ways
and discussed the various skills
they'd be working on together during their treatment.
This included relaxation strategies to help Jack
calm his nervous system,
identifying how factors such as skipped meals,
stress, and poor sleep can contribute to headache symptoms,
specific strategies he can use in the moment
when those headache symptoms come on,
how he can combat any unhelpful thoughts related to headache
and the way this can impact how he feels
and the actions he takes.
It also included creating a headache self-management plan
that combines both preventive and acute strategies.
-So, Jack, after what we've discussed, what do you think?
-Yes, let's do this.
-Jack decided that he wanted to receive his care via telehealth
at a time that was more convenient for him.
-Hi, Jack. Welcome.
It's very nice to meet you.
Today, I'd like to get to know you better.
I'm here to understand how your head pain and symptoms
have impacted you,
your quality of life, as well as your mood and sleep.
My hope is that we can work together
so that you can learn ways to decrease
how often you get your headache symptoms
and how severe they are when you do get them.
During our treatment,
I'll be teaching you various skills to try out at home
and helping you figure out
what combination of these tools work best for you.
Together, we'll come up with some goals
that you'd like to be working on throughout our treatment
to make sure we're focusing on the parts of your life
that are most important to you.
-Jack wanted to understand more about how these skills
might help him.
-I've tried a couple of these things before.
I did the breathing thing,
and now I always get a headache when I drink a glass of wine.
How is this treatment different, and how can this help me now?
-That's a great question, and I'm really glad you asked it.
Migraine is a complex neurological disease.
People with migraine have a nervous system
that is very sensitive to changes in the environment.
Now, even though your biology makes you more likely
to develop head pain and symptoms,
there are other important factors,
both internal and external, that can change the likelihood
of you having a headache on a given day.
I'd like to give you some more information
about the headache threshold
based on what you've shared with me so far.
Is that okay?
-Thanks. That would be helpful.
-Everyone has their own unique threshold
that determines whether they get an increase
in their headache symptoms on a given day.
Take a look at this picture.
I want you to imagine that this green line
is your own personal headache threshold.
Now imagine that every time one of these factors is in your day,
we add it to the jar.
You just shared with me that your sleep isn't great,
you often feel overwhelmed,
and you skip meals a few times a week.
So let's add those to the jar.
As you experience more and more of these events,
your jar fills up.
When your jar overflows,
this is when your headache symptoms might progress.
As we just talked about, your brain is very sensitive
to changes in your environment and doesn't always adapt easily,
which explains how the same trigger
doesn't always result in headache pain and symptoms.
It's usually the combination of factors that move you
toward that threshold.
Now, your threshold doesn't start from zero each day,
so a bad night's sleep or a skipped meal on Monday
can impact your headache symptoms a few days later.
During this treatment, we're going to work together
while you learn more about the factors
that may contribute to your symptoms.
And I'll teach you skills that you can use
to help move that threshold.
Think of it like opening the tap to the jar or emptying it out.
-Hmm. That makes sense.
I never really thought about it like that.
I really hope this treatment helps me.
-Jack worked with his doctor to find a treatment plan
that worked for him.
-Thank you for taking the time to talk with me today.
I appreciate your willingness to be open
about your experience living with migraine.
Now that you've heard about what our treatment entails,
do you think this is something you'd be interested in trying?
-This is something I can get behind.
Thanks, Doc.
-Working with his doctor, Jack felt more confident
and started taking a more active role
in managing his head pain and symptoms.
He felt more control over his health and life
and had less headache days.
He was able to be more productive at work,
spend more time playing with his kids,
and overall enjoyed a happier and healthier life
despite his head pain and symptoms.