Coping with headache

Abstract

Objective. To describe self-initiated actions and cognitive strategies used for coping by women who suffer from episodic tension-type headache. Design. Qualitative data from focus-group interviews were analysed according to Giorgi's phenomenological approach, inspired by Lazarus's theory of coping. Subjects. A total of 15 women with tension-type headache, 20–60 years old, were recruited to three different focus groups through newspaper advertising. Results. To cope with episodic tension-type headache, rhythm and balance in actions like eating, drinking, and sleeping were essential. Several women used thermal modulation. Exercise was important. Taking charge of their own time, pace, and level of commitment and accepting the fact that they had to live with their headache were cognitive strategies used. Implications. The general practitioner should identify the woman's choice of actions and cognitive strategies to manage her headache, and support her coping skills.

• Action
• coping
• headache
• qualitative

Tension-type headache is a discomfort that most of us experience from time to time [1–3]. Usually, headache is perceived as a nuisance, which is managed well, but for some episodic headache constitutes a more severe health problem. Family and social activities are affected, and workdays may be lost due to the level of pain [1]. Medical solutions to this problem are limited, yet general practitioners frequently encounter patients with chronic disabling symptoms.

Migraine is a well-explained medical entity, and there is some evidence of the pathophysiology of tension-type headache [4]. Even so, tension-type headache presenting with subjective symptoms without objective findings is still not fully understood in medical terms. Peters et al. found that headache sufferers adapted symptom management to suit their needs and preferences in an individual style [5], [6]. Use of healthcare, medication, and alternative therapies constituted only a limited part of their coping strategies. More specific approaches to social support, lifestyle, and self-management demonstrated how headache patients play a central role within their own care.

Women with episodic tension-type headache choose individual means of getting relief. Their experiences reflect a wide range of coping strategies.

• Self-initiated actions such as being considerate about fundamental bodily rhythms (eating, drinking, sleeping, exercising, thermal modulation) to balance everyday life were used.

• Cognitive strategies like taking charge over their own pace and commitment and acceptance of their headache were used.

• The general practitioner should identify the woman's choice of actions and cognitive strategies to manage her headache and support her coping skills.

Patients with medically unexplained disorders complain of not being taken seriously by their doctors [7], and doctors become frustrated seeing patients with disorders they are not able to understand or cure [8]. Cognitive therapy, making the patient reattribute his or her thought patterns, has been proposed [9]. However, for appropriate healthcare to patients with medically unexplained disorders, doctors' thought patterns may also deserve reattribution. Using patients' symptom experiences as knowledge resources [10], we may be aided in understanding and interpreting their situation [11]. Shifting attention from patients' disorders to their personal health resources may provide access to new dialogues, better suited for establishing common ground [12].

We therefore decided to identify and describe self-initiated actions and cognitive strategies for relief and coping used by people who suffer from episodic tension-type headache. For all types of headache, prevalence is higher for women than for men, including tension-type headache [1–3]. Coping strategies may be gender specific [13]. In this study we chose to concentrate on experiences of women headache sufferers.

Design, material and methods

The findings are drawn from analysis of three qualitative focus-group interviews. Informants were recruited through advertising in a major regional newspaper. Informants suffering from migraine or other diseases known to cause headache were excluded from participating in this study after telephone screening. A total of 15 women aged 20–60 years old were recruited, comprising some from various occupations, students and persons on disability pension. Married, cohabitants, and single women were included in the study. All the informants had been suffering from headaches for more than a year, most for a period of 10–20 years, with the older women suffering the longest. They were divided into three groups according to age. Most informants had weekly headaches, some had daily headaches, and some more seldom.

The interview followed focus-group principles [14]. The moderator (KM) invited the participants to share experiences from their everyday life with headache, asking about coping experiences and images of headache causes. Conclusions from analysis of causal images will be presented in a later article.

The conversations in Norwegian were audiotaped and the transcripts from the interviews were compiled into one body of text. Qualitative analysis was inspired by Giorgi's phenomenological approach. The approach is a descriptive procedure for handling the data, which has four stages: (1) read all the material to get an overall impression, bracketing previous preconceptions and choosing preliminary themes, (2) identify units of meaning that represent different aspects of the material, and code these, (3) condense and abstract the meaning within each coded group, (4) summarize the content within each group to establish concepts that reflect the main varieties of actions and strategies used by the women to cope with their headache [15], [16]. We further analysed the data following Miller & Crabtree's editing analysis style [17] where the categories emerged from a reading of our empirical data, supported by theoretical perspectives on coping [18].

Here, we present findings from data dealing with actions and cognitive strategies the women initiated on their own, emphasizing nuances and varieties among the informants. Data on medication and help-seeking behaviour acquiring services from various health professionals was omitted from the analysis.

Results

The informants told us that it was essential to obtain their own preferred rhythm and balance in fundamental bodily functions to cope with their headaches. Taking charge of their own life, including their symptoms, was the cognitive strategy used. These findings will be elaborated below.

Rhythm and balance

A number of the women talked about the importance of eating and drinking at regular intervals, eating wholesome foods, not sweets. They pointed out that the headaches were less severe when they became more attentive to their eating habits.

An important issue mentioned by several informants was the need they felt to drink enough water and coffee. Many of the women stated that drinking a sufficient amount of water was an effective way to manage the headaches. In the same manner they described drinking coffee. Coffee was their substance of choice to manage headaches, and was drunk on a daily basis by many of the women. A student in her twenties described the effect coffee had on her like this:

I've experienced relief from coffee, right then and there. So if the headache is really intense and I'm visiting someone, and if I drink a full cup of coffee, I think my headache eases off a little. Just like there is a poison in my brain, that is what it feels like, and then whoosh, the coffee almost pushes the poison aside. And then the headache eases off, for a while anyway. (#D)

The women also emphasized the importance of getting enough sleep. They agreed that being rested with neither too little sleep or oversleeping was a big help.

Thermal modulation

Thermal modulation was used to ease their headaches and several found this to be effective. One woman especially talked about using a massage shower where she used water as hot as she could bear in order to get relief and time off from her pain. Some of the 50-year-old informants said that they preferred specific actions to cool down their temperature, like this woman:

I feel the thing about using a very, very cold washcloth and put it on my forehead, with ice-cubes in it. I mean, at least the washcloth cools my forehead down … and I have headaches in my forehead. And I have the sensation that my forehead sometimes burns up, and then it feels good to be cooled down. Really. (#G)

However, for some individuals, the temperature should neither be too warm nor too cold. They preferred a balanced temperature around themselves.

Staying fit

A number of the women talked about how regular exercise helped. In periods when they did not exercise, they discovered that their headaches were worse than in periods when they did. They mentioned various activities, e.g. brisk walks, weight training and karate. A retired hairdresser summed up the value of staying in shape by saying:

So I think if one stays reasonably fit and works out, then it helps. (#H)

Taking charge

One strategy of choice among the women to handle their headaches was different ways of taking charge of their own life. This meant taking charge over their own time, pace, and level of commitment. They had to learn to relax and accept the fact they could not achieve everything they wanted to do, without feeling guilty. When they managed this, many experienced that their headaches wore off, like this woman:

It is my life! I try to take control by stopping for a while and being aware of the headache, and at some point I don't feel anything, my headache's gone. (#D)

Never mind

A common insight among the women was that they had to learn to live with their headache and accept the presence of the headache. They had to convince themselves that this was just the way things were; some of the women based their conclusion on decades of experience.

A lawyer with weekly headaches spoke of a specific approach. Together with some friends, she established a group of women with diverse complaints who got together for social support. They had a discussion in an amusing and ironic setting and decided which issues truly were worth attention, thus dealing only with the important issues, letting the “smaller” ones go.

But I think some women get different complaints than headaches from the same troubles. They get stomach aches, neck pain. And I have other female friends that also think too much and try to do too much, so we've made this little club that we call “The Never-Mind-Club”. Like, because we don't have to take things so seriously, just let the others manage their own lives, we can't solve every problem and can't always be available. So we just “never-mind” this, and “never-mind” that, and then we get some issues that we rate highly and those are the ones we go for. (#A)

Discussion

Whose experiences did we hear about?

The sample was established through a newspaper advertisement. Proactively, the women included themselves in the study, stating that they were headache sufferers; no medical certificate was needed to be eligible. One could question whether the informants really met the International Headache Society (IHS) criteria for tension-type headache [19], since most had not been formally diagnosed and recruited through medical channels. On the other hand, the population of women suffering from tension-type headache on the list of a general practitioner is usually a varied one, some with a diagnosis and some without. We do not know whether our patients represent typical patients on a general practitioner's list, but we believe them to be typical sufferers of tension-type headache. Another possibility is that our informants do not regularly visit their general practitioner because they manage their headaches on their own.

Our study did not explore the impact of potentially substantial differences in the coping skills among the participants. We know little of the background of the participants except age, marital status, line of work, and headache experience. We do not have information about the women's use of medication.

Choosing a focus-group design, we may have emphasized the statements from those of our informants who were most verbally gifted, perhaps those who were most self-confident. Yet, since our theoretical perspective was a resource-oriented one, such voices might be especially well suited to mediate experiences perceived as positive.

Can the strategies presented here be recommended?

This is a descriptive study, presenting stories about actions and strategies the women undertake and initiate themselves. We wanted to broaden the scope of issues invited into medical dialogues around one of the medically unexplained disorders, by considering the actions and strategies presented as potential lay health resources. Focusing on the actions undertaken by the women, without assigning any biomedical value to the actions, we intended to demonstrate some of the everyday life efforts taken by chronic pain sufferers and relay this knowledge into clinical domains.

Our intention was neither to evaluate the effect of the phenomena described, nor to check out their rational or biomedical foundations. Several authors describe actions and cognitive strategies in dealing with various chronic disorders, and discuss how patients are making life adjustments to cope with their ailment, with regard to a focus on experience and control over their life and their disorders [10], [20–22]. Studies in self-management of diseases reveal that utilizing one's own resources has a marked effect on the perception of one's disease and provides tools to handle one's disease [6]. Penzien et al. [23] present a review of the use of cognitive and behavioural strategies in patients with tension-type headache. The authors also present a self-management model for patients with tension-type headache in a primary care setting. The women in this study, although not in a clinical setting, engage in actions and cognitive strategies that are taught in this model.

Well-known issues?

Many of the actions undertaken by the women did not represent new medical knowledge. Thermal modulation and regular exercise are methods used by other healthcare professionals in aiding headache patients. Since one of us (RS) is also a licensed physiotherapist, such actions might have been especially easily identified during analysis. The strong advocacy of maintaining good eating and sleeping habits constitutes common advice on many websites offering advice to headache sufferers, as well as using various methods of stress management as prophylactic treatment, e.g. relaxation therapy, biofeedback, and cognitive-behavioural therapy. What our data add is information concerning the great variety of what individuals perceive as helpful. Drinking water prevents dehydration, a known cause of headache. Having to drink coffee and getting relief from drinking it may suggest caffeine withdrawal symptoms. The action of drinking coffee may also be an example of an action laypeople take to get immediate relief, and the solution may work but is not necessarily the best in the long run. The coffee drinking was seen as a prerequisite of daily life, as a fundamental rhythm, but were the headache to be a withdrawal symptom, a better long-term solution would perhaps be to stop drinking coffee.

Empowerment and coping

Encouragement and validation regarding patients' concerns about the condition are important tasks for the general practitioner when seeing patients with medically unexplained disorders [21]. It is important to enhance positive coping strategies and find alternatives to negative strategies. Empowerment is a process to support self-determination, oppose social injustice, and amplify the voice of vulnerable individuals [24]. For the purpose of coping with medically unexplained disorders, such as episodic tension-type headache, empowerment would be an adequate approach to understand the patient's life conditions, and support patients in taking charge of their disorder and their lives.

We do not consider headache as a condition caused by social injustice. However, the gender dimension on economic and social disadvantage still makes it a special challenge for women, even in a country like Norway, to obtain satisfactory control over the rhythms and balances of everyday life. Careful listening and exploration of strategies established by creative patients might teach the doctor some lessons about these issues.

Lazarus and Folkman [18] have identified the main ways of coping: (1) problem-focused coping and (2) emotion-focused coping. Problem-focused coping is hailed as the most fruitful approach as its aim is to eliminate the source of the stressor, while emotional-focused coping attempts to regulate the emotional consequences of the stressor. The women in this study used mainly problem-focused coping, trying to adjust external factors of their daily life, and they also utilized social support.

Taking charge – never mind

We were impressed on hearing about the never-mind-club, presented as a humorous self-help group with the specific strength to identify the important issues and deal with them appropriately. This story describes a strategy that it is hoped can be adopted by other female headache sufferers. The impact of the never-mind-club has the ability to be recognized beyond the context of being a woman suffering from episodic headache. The strength of this group appears to be not only the getting-together aspect, but also perhaps even more the shared strength of promoting self-determination within a group of peers.

So what

We have presented stories from the women relating the importance of taking various self-initiated actions and cognitive strategies to manage their headaches in an everyday life setting. Although these approaches were perceived as effective tools for these women in handling their headaches, they would not necessarily work for others. However, some of our findings are transferable to a broader clinical context. The importance of taking charge of fundamental bodily rhythms and balances of everyday life could apply to coping with various chronic disorders, although the individual needs might vary greatly. For patients with medically unexplained disorders, empowering dialogues can provide the encouragement and validation necessary to identify actions and cognitive strategies used for coping. Supporting the patient's strong aspects in such specific ways can be an important task for the general practitioner dealing with episodic tension-type headache, instead of letting frustration grow. This would be our advice to the general practitioner.