Comprehensive Concussion and Migraine Care Q&A with Dr. Kyle Klitsch

The brain is our body’s control center, containing about 100 billion microscopic cells called neurons that impact how we think, feel, move and learn. When a concussion occurs or migraine headaches happen regularly, the brain and the body may need help returning to normal function.

Good Shepherd Rehabilitation’s Kyle Klitsch, DO, is a physiatrist specializing in concussion management and migraine care. We asked Dr. Klitsch to explain concussions and migraines and how they are clinically managed and comprehensively treated.

What is a concussion and what causes them?

Dr. Klitsch: A concussion is a mild traumatic brain injury that may occur as a result of a direct blow to the head, face or neck. The injury causes the brain to stretch and damages nerves and blood vessels, resulting in a complex chemical reaction that causes the brain to redirect its energy to healing.

A concussion disrupts normal functioning and may impact vision, cognition, balance and movement. A concussion may be sustained with or without loss of consciousness. People of any age may experience an injury that causes a concussion. The most common causes include motor vehicle accidents, falls, sports injuries, violent attacks (physical assault or domestic violence) and blast injuries experienced by military personnel.

Concussions are graded by severity into three levels:

• Grade 1: Mild concussion with no loss of consciousness, or amnesia that lasts less than 30 minutes
• Grade 2: Moderate concussion with loss of consciousness for less than 5 minutes or amnesia that lasts between 30 minutes and 24 hours
• Grade 3: Severe concussion with loss of consciousness for more than 5 minutes or amnesia that lasts more than 24 hours 

What are the symptoms of a concussion?

Dr. Klitsch: Concussions may cause symptoms that last hours, days, weeks or months. Good Shepherd uses a post-concussion symptom scale to assess the number and intensity of symptoms. Patients will usually have multiple symptoms from these four categories:

1. Physical: Headache, dizziness, nausea, vomiting, balance problems, light and sound sensitivity, blurred vision, difficulty focusing vision, fatigue
2. Cognitive: concentration problems, memory problems
3. Emotional: Anxiety, irritability, depression
4. Sleep: Difficulty falling asleep, sleeping more, sleeping less

What type of physicians treat concussions?

Dr. Klitsch: The majority of patients will first present at a hospital emergency department, and the ER physician may immediately diagnose a concussion. Primary care physicians may also initially see patients with concussions.

Depending on the severity of the concussion, a patient may be referred for care to a concussion center run by physician specialists. For example, a sports medicine physician may see concussion patients who suffered a sports injury. Those with prolonged or serious symptoms will be referred to a physiatrist or neurologist.

What are the benefits of seeing a physiatrist for a concussion?

Dr. Klitsch: Concussion care by a physiatrist, or physical medicine and rehabilitation physician, offers a unique perspective and focus on functional recovery. As physiatrists, we manage the whole patient, conducting a comprehensive exam and prescribing treatment based on all the patient’s symptoms and the severity of the concussion.

Good Shepherd offers a multidisciplinary approach to treatment that addresses all physical and cognitive issues, including vision problems, musculoskeletal pain and vestibular (balance/dizziness) issues. Our offerings include:

• Neuropsychology
• Physical therapy
• Occupational therapy
• Speech therapy
• Vision therapy
• Vestibular therapy
• Headache management
• Medication management

The advantage of Good Shepherd’s comprehensive care is that there typically is no need to see different specialists at different locations for different physical and cognitive issues related to a concussion.

What are the specific roles of therapies in concussion care?

Dr. Klitsch: Each therapy discipline works with the patient to reduce the severity of symptoms, reduce recovery time, improve function, prevent complications and reduce the risk of re-injury. The therapists in each discipline work collaboratively and communicate easily to advance the patient’s care.

• Physical therapy: musculoskeletal rehabilitation, vestibular/balance therapy, sport-focused rehab (so athletes can return to play)
• Occupational therapy: vision therapy (in coordination with physical therapy)
• Speech therapy: cognitive therapy
• Neuropsychology: coping with personality and mood changes and challenges processing information

Good Shepherd hosts a Concussion Support Group as a supportive forum and idea exchange for those recovering from concussion. Patients and their caregivers share successes and challenges and learn from one another. The group meets virtually at 6 p.m. on the fourth Tuesday of each month. For information, contact dhalteman@gsrh.org or mmickley@gsrh.org,

Can you prevent another concussion?

Dr. Klitsch: There is no way to entirely prevent a concussion, but allowing for a full recovery before returning to normal activities is important, especially for athletes.

Good Shepherd specializes in treating athletes and non-athletes who have sustained a concussion. Athletes must wear proper protective gear and use proper techniques when returning to sports after a concussion. Balance/coordination and core strength can reduce future injuries.

For older patients and others at an increased risk of falling, it is important to evaluate the living environment. Our therapists may visit a patient’s home to determine what caused a fall and recommend how to improve the environment to reduce the risk of another fall. That includes looking at stairs, rugs, furniture placement and the need for rails in bathrooms.

Concussions often cause headaches. What headache care does Good Shepherd provide?

Dr. Klitsch: Good Shepherd’s headache care helps individuals manage and alleviate the pain and discomfort associated with various types of headaches, including migraines, tension headaches and cluster headaches. The goal is to reduce the frequency and severity of headaches and improve a patient’s quality of life.

Good Shepherd’s experienced healthcare professionals collaborate to develop a personalized treatment plan for each patient. It begins with a comprehensive assessment to understand the root causes of and triggers for headaches.

You specialize in migraine care. How are migraines diagnosed?

Dr. Klitsch: Migraines are a clinical diagnosis based on the patient’s medical history and a physical and neurological exam.

A migraine is defined by these elements:

• At least five or more attacks in a lifetime
• Headache attack lasting 4-72 hours
• At least two out of four features: unilateral location, pulsating/throbbing quality, moderate-severe intensity, aggravation by/causing avoidance of routine physical activity
• At least one of the following features: nausea and/or vomiting, sensitivity to light, sensitivity to sound

Why do migraines occur?

Dr. Klitsch: There isn’t one cause. Often a genetic predisposition makes people more susceptible. Hormonal factors can predispose women to migraines. Sleep issues and dietary issues, such as consuming foods like processed meat, alcohol and caffeine, can cause migraines. There are also environmental factors like barometric pressure and weather changes. I see a lot of patients who have bad migraines during the summer due to weather changes.

What does a physiatrist do for migraines?

Dr. Klitsch: Physiatrists play a valuable role in treating migraines and other headaches, especially when there are underlying medical or neurological factors contributing to the headaches.

Migraine and headache management may include medical management, Botox® injections, trigger point injections and occipital nerve blocks.

Migraines are most frequently treated with medications. For infrequent episodes, a rescue medication will be prescribed for when a migraine is starting. If someone experiences migraines 15 days a month or more, preventative medicine and rescue medicine will be used.

For migraine patients who require medication, we coordinate with our neuropsychology team to treat anxiety and depression symptoms.

Can physical therapy help with migraines?

Dr. Klitsch:Physical therapy can help with muscle tension, improved posture and headache frequency. Our therapists provide guidance on lifestyle modifications, including dietary changes, stress reduction techniques and ergonomic adjustment. Cognitive behavioral therapy techniques help patients better manage stress, anxiety and other psychological factors that can trigger or exacerbate migraines.

How does Botox® help with migraines?

Dr. Klitsch: Some patients with migraines may benefit from Botox® injections. The leading theory is that Botox® relieves compression on the small cranial nerves.

Good Shepherd evaluates candidates for Botox® migraine treatment very carefully. The screening includes a thorough physical examination, health history review, review of failed medications and treatments, and additional non-invasive testing to determine if Botox®  treatment is appropriate.

To learn more about concussion or headache/migraine care, call 1-888-447-3422 (44-REHAB).