S6:Ep2 – Physical Therapy as a Migraine Treatment
Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. In this episode of Spotlight on Migraine, physical therapist Dr. Sam Kelokates explains how physical therapy can be a helpful treatment option for people living with migraine. He talks about various physical therapy techniques, possible benefits, and how to get started.
Molly O’Brien: Hello, and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien.
One of the most common questions people ask is, how can I manage migraine without using medication? Well, today we’re going to discuss one of those options: physical therapy.
I’d like to introduce our guest, Sam Kelokates. Sam is a headache physical therapist at Kelos Physical Therapy. Sam has an extensive background in neurological disorders and is an expert on treating and managing chronic pain. In 2021, Sam started his own practice to help people living with headache disorders.
Sam, thanks so much for joining us.
Sam Kelokates: I’m great, Molly, thank you for asking and asking me to join you tonight.
O’Brien: So as we dive in, I just want to mention that in your practice, you focus on physical therapy for headache relief. And I do want to mention that we’re going to talk about migraine, tension-type headaches, and neck pain, for our audience out there.
So let’s dive in. How does physical therapy affect migraine?
Kelokates: One is by trying to reduce the frequency, the intensity, and the duration of attacks. And there’s different strategies we can utilize to really help patients with each kind of area or, I guess, like parameter of their headache type. There’s different ways we influence that, whether it’s through exercise, manual therapy, or in using modalities. And we’re trying to really change how sensitized your neurological system is that keeps triggering these attacks.
O’Brien: So what are some of the potential benefits that people can experience if they use physical therapy to help manage migraine and headache?
Kelokates: I do want to clarify that physical therapy isn’t necessarily a specific technique, or intervention, or philosophy because there’s a lot of different approaches within this. Physical therapy itself is a profession. So there’s many different thoughts about how we help people with chronic pain.
Back for like the benefits, the benefits we’re looking at is to, obviously, decrease how frequently you’re having attacks and to give you strategies to better manage them independently through nonpharmacological means. So again, exercise, manual therapies, and modalities. Modalities, I’m referring to like hot, cold, and neuromodulation, especially with that being so big today.
O’Brien: You mentioned a couple methods using hot and cold, using exercises. Are there any other techniques or methods that physical therapists might use to help someone manage migraine?
Kelokates: One of the skills we have that we’re able to help people with migraine better manage their condition is doing lifestyle interventions or giving them different strategies to manage at home, whether that’s grounding techniques if they have vestibular migraine, or giving them stress management strategies where they were in under a large amount of stress, whether at work or with family, and how they come down from those stresses so they don’t trigger attacks and make them more resilient overall. So that’d be more like the lifestyle side of healthcare.
O’Brien: And I want to just go back briefly. A lot of people might have an outdated view of what physical therapy is. They might think one specific type of person is the only type of person that can utilize physical therapy. Can you give us just kind of a brief overview of what physical therapy is? And it sounds like a lot of people can benefit.
Kelokates: So a lot of people can benefit. Once upon a time, it was more that physical therapy kind of solely focused on musculoskeletal disorders or people that were kind of more infirm and needed a lot of help getting in and out of bed. But over the years and as research has grown, our expertise has expanded into multiple domains, whether it’s neurological disorders like migraine or vestibular dysfunction, musculoskeletal, burns, oncology care. There’s a lot of different groups of people that we can help with physical therapy.
Physical therapy now has become more modernized. And we have a different, a more holistic approach to seeing patients, and it’s much more patient-centered. So we really consider what the patient goal is, what their condition is, their values, and taking really into account like how do they want to get better, and it’s more of a collaborative process now.
O’Brien: Oh, I love that. The collaborative process. It’s not just, here’s the exercises, go do them. I’ll see you next week.
Kelokates: You know, we’re not going to get the benefits of the physical therapy if we’re not communicating on what’s working for you and what’s not, especially with migraine. Because some of our treatments might actually make you feel worse at that time or the day or two later, we need to talk about, okay, is this you just didn’t have a good response to that particular intervention? Is it everything we’re doing is irritating your condition, and do we really need to work together to modify what we’re doing, or is it, no, I think that’s just an outlier, let’s try it a few more times and make some changes here and there to make sure we’re not constantly triggering attacks with interventions.
O’Brien: Let’s get back on track to we talked about a little bit of the benefits of physical therapy for migraine and managing headache. Let’s go into some of those risks. Because you mentioned some people might actually get worse before they get better, or some interventions might actually trigger attack. So talk to us about some if there are any potential risks.
Kelokates: There’s no real risks with seeing physical therapy for migraine. You might occasionally get trigger from attack, but you can also get triggered by attacks just because it was that day of the week, and we don’t really know why. So we can’t always correlate everything to physical therapy. That’s why that collaborative, communication with your therapist is really important.
Now, there are times where I’d make sure that if every time they do a certain exercise or a manual therapy technique, it’s like, no, I feel way worse after that, then they need to change that treatment approach and avoid that activity because, obviously, that’s something that we want to avoid. Now, does that mean we can’t revisit it later if we think it’s an appropriate exercise or treatment? Yes, we can, but maybe that’s something that you’re just not ready for, and we need to get back to it.
Some other people that might need to be a little more cautious about getting into physical therapy is people with like additional comorbidities, like hypermobility syndromes like EDS or who have POTS. Physical therapy can work with those individuals as well and those individual conditions, but when we have migraine as well as POTS, as well as EDS, and a lot of patients that I see have all three conditions, that we need to work together on really figuring out, okay, where do we want to start really focusing? What treatment might irritate another condition? And how do we prevent that?
O’Brien: Can you talk to us about is there any type of person that might benefit the most from utilizing physical therapy, and, on the flip side, is there anyone that might not benefit or just really should not try physical therapy for migraine or headache?
Kelokates: For the people that would benefit the most, I think if you’re having neck pain with your headache, whether it comes on before, during, or after, there’s a higher potential benefit of physical therapy just because the neck seems to be involved in some way, whether it is a primary trigger or it’s being referred to from migraine, which can also happen. So sometimes, you can have neck pain with migraine, but that doesn’t necessarily mean anything is wrong with your neck. But we can’t do that until we screen for it. Right?
Then there’s other things that we can do as far as, let’s say, you don’t have a neck problem, but we’re able to stimulate or trigger your familiar headache. We can do manual and exercise interventions to help with that. And let’s say…there’s like a patient I saw last week that I wasn’t able to reproduce their headache in any way. Typically, if I’m not able to reproduce any types of symptoms, those people are less likely to benefit from the hands-on physical therapy of every session. But what they would benefit more from is getting on a, if they don’t already do it, a regular physical activity program, both generalized like aerobic and generalized strength and then a neck-and-shoulder-specific strength program.
O’Brien: I like that idea. I need to get in there. Do you look at physical therapy as an acute or preventive option for migraine, or is it both?
Kelokates: I look more to physical therapy as a preventative measure, so we’re looking to decrease your attacks over time, so to help prevent them and improve your body’s ability to reduce triggers. But it can be used acutely as well. I’ve had patients come in with a migraine attack and be able to leave without one. I feel that’s not a common occurrence, though.
I feel like once they come in with a migraine, I can lessen some of their symptoms but not abort them completely. So it can be used as an acute, but I don’t think it’s a strong part of physical therapy in the management of migraine. I think we’re looking to help you on the long term, so reducing headaches from 15, 20 days a month and getting you down to less than 4 a month.
O’Brien: And you had earlier mentioned a little bit about vestibular migraine and physical therapy for vestibular migraine. Are the approaches the same? Are they different? Can you briefly tell us a little bit about that?
Kelokates: As far as the evaluation goes, I think the evaluation should be the same. I’m going to be looking for those types of triggers and symptoms during the examination.
What would change, over the course of that plan of care, would be the types of interventions or exercises that you’re doing are meant to more stimulate your vestibular system and how your brain integrates that vestibular information from the ears, the eyes, and the upper cervical spine, to decrease that vestibular trigger for you.
O’Brien: Can you…and obviously every clinic is different…but overall, in general, if someone is interested in utilizing physical therapy for migraine or managing their headache, can you walk us what a first visit looks like? Do we just walk right in and hop on a table? Do you need X-rays or imaging? Is it more about the conversation? What does the first visit look like?
Kelokates: So I don’t need an X-ray or MRI or anything. The only times I would really want that information first is if you just got out of a traumatic injury that’s either exacerbated your headache condition or has caused your headache condition. So like a whiplash injury, concussion, a fall down the stairs, that we really need to make sure that structurally everything is okay and safe to use physical therapy interventions because sometimes it might not be until that itself is corrected. And that might mean surgery or other medical type care before you come to physical therapy.
So a first session with me is somebody comes in, we do our intake, they fill out all their paperwork. And then we sit down, and usually the first 20 minutes, 30 minutes of our session is really going through this objective. What is their experience with migraine? How does it present to them? What is their pain like? Do they actually experience just migraine, or they’re experiencing other headache types with migraine because that is also pretty common to also have tension headache or something else going on, and differentiating those two headaches and what their potential triggers are.
And if they don’t have triggers, we go into, okay, we need to start tracking this while we’re in therapy together so I can see what might be is benefiting you or what is not benefiting you and really help kind of hone in on certain treatments and what’s going to be most effective for you. Because I don’t want to give four or five exercises, fix this sleep pattern, talk about this diet issue. If I only need to talk about one or two issues, I’d rather just focus on one or two issues.
Then once we go through this objective, which that gives me a lot of information on what I want to do with my physical exam, we get into the physical exam. I generally look at range of motion or other musculoskeletal issues like trigger points, joint mobility, which is a little bit different than range of motion. And then the newer technique that utilizes what’s kind of reproduction and resolution technique or test, where we’re trying to see if we’re able to reproduce your familiar headache, whether that’s migraine or tension-type headache and reproduce that with this manual technique, and then also resolve it with that same technique.
O’Brien: Wow. That sounds fascinating.
Kelokates: It’s pretty fascinating. And it’s actually the treatment itself, which is really cool and fun to see it as well.
But once we get through that physical exam, we sit down, we talk about what I think we might need from a lifestyle management perspective. Okay, these are the areas where we want to start focusing at home, here’s where I think we need to do in physical therapy, and this is how long I think the treatment plan is going to be. And here’s what might cause us to take longer to achieve your goals if like certain things come up or you’re not responding well or certain exercises are becoming problematic, where I thought they would be effective, they are actually not helping us.
O’Brien: And a lot of things you said seem to me like it’s really good for people to listen, watch, read this before they head into a physical therapy appointment because if they have an idea of what’s coming, then they can prepare and maybe get more out of their first session or appointment, whatever it is, just to be prepared.
Kelokates: Yeah, I think the biggest thing is to be prepared is that if you’re not already doing it now and you’re having frequent migraine or other headache attacks, is to start recording that information, how many days a week you’re doing it, any perceived triggers, what medications or other things are helping you feel better, whether it’s like laying down, a hot shower, an ice pack on the head. That information can really tell us how you’re managing at home and also give us a point of reference of, okay, this is where you are when you came in. Where are we trying to get you to? Are you at 16 headache days a month? Great. Okay, we go through our treatments. Oh, now you’re kind of going up? This doesn’t seem to be working, should we stop? Or are we seeing that you’re getting better, but something seems to be missing? What other treatments can we start doing?
Or are we starting to notice, you know what, your headache days haven’t changed, but you’re taking less medications to get rid of your headache, and now you’re just using your neuromodulation device, or now you’re just laying down in bed for an hour or two and getting up, and you feel like you can still participate in the rest of your day. Right? So because just having less headache days isn’t the only way to measure success. Sometimes it’s are you accomplishing more? Are you able to go out longer for longer periods of time with your family and friends? Are you able to eat certain foods or get more rest than you usually are? Certain things show improvements before, necessarily, the headache days improve.
O’Brien: So Sam, along those lines of preparing for your first session, kind of giving people an idea of what they can expect, how can someone actually get started doing physical therapy for migraine and/or headache? Do we need a referral slip from our primary care? Can we just walk in? Can you call up anybody you want? Do you look for a specialist? How can you go about getting started?
Kelokates: I would definitely look for a specialist or at least somebody that is familiar with neck pain, preferably headache, but there’s not many in the US that focus specifically on headaches. I only know five other therapists in the United States that specifically do that, at least those are the ones I’ve been able to find online. I’m sure more are out there, just their presence online isn’t as strong as some other people.
You don’t need a prescription to get started with physical therapy in most states. You can just call the clinic and ask for an evaluation. Like here in Pennsylvania, I can treat patients for 30 days without a prescription. If I feel like treatment plans are going to go over that, then I reach out to the physician and get that prescription if I don’t already have it.
O’Brien: Okay, good to know. And yes, thank you for clarifying because, obviously, every circumstance is different, and every state is different, especially with insurance.
Kelokates: I think the majority of states have direct access now, so you can just go to physical therapy. Now, that specific clinic might say we’re not going to see you until we have that. That’s just part of their policies and procedures. But in most states, no, you do not need to.
I wouldn’t just go to every…like I was mentioning before, I wouldn’t go to just any physical therapist, I would try to find people that specialize. I know in more rural communities that might be even more difficult. But that’s not something that those therapists should be able to reach out to somebody like myself or other people that are experts in the conditions because we’re more than happy to help guide them on possible treatments and reach those patients that we can’t necessarily provide care to because of our geographic locations.
O’Brien: Because we were kind of on that track, let’s talk a little bit about how we mentioned that insurance is different for everyone. But from what you’ve kind of seen in your practice, giving kind of a ballpark generalization, does insurance cover physical therapy for migraine? And for folks who might pay out of pocket, what are we looking at for a typical session? Just in general if you can.
Kelokates: Insurance should cover physical therapy for migraine because we wouldn’t really say…there’s not like that limitation just because of the diagnosis that we’re not being able to treat for physical therapy, so they would. There’s other issues that the insurance company might want. Like they might want you to start with a referral first, and they will not cover sessions that weren’t being referred to.
You might also require a prior authorization. That’s dependent on the insurance provider you have. So before you even go to physical therapy, your doctor needs to submit a prior authorization so you get permission to do physical therapy from your insurance provider. And there’s a lot that can kind of go into it.
Here in my clinic, I’m an out-of-network provider. So what that means is that patients provide payment to me up front, and then we’re submitting reimbursement claims back to their insurance provider. I’m somewhere in like the median of prices for out-of-network costs, which is about $200 for a one-hour session.
O’Brien: So I feel like we’ve covered a lot here. And I want to give people just a little tidbit to get them started, get them excited about using physical therapy for migraine. Are there any tools, approaches, stretches? Is there anything that we might be able to do at home to help us as we incorporate these tips into our daily life, to maybe help reduce the impact of migraine? Or is there anything that’s safe? You know, this is a one-size-fits-all, so want to make that clear. But is there anything that people can start to do at home to help them with migraine?
Kelokates: I think the biggest thing to start doing, from a physical therapy perspective, is to start becoming more physically active. I don’t want to necessarily say exercise because that can mean different things for different people, and I feel like we’ve gotten to the point with a lot of people accusing people of not exercising enough, and that becomes patient blaming. And it’s really hard to exercise when you have a chronic pain condition.
But I want to find ways to start becoming more physically active, whether it’s just walking, playing with your kids, gardening. That’s always a good place to start because physical activity is really necessary for the body because it has a lot of different effects, both physiologically and neurologically, on how movement and exercise affects our brain, how we work to integrate different sensory-type information. So that’s the best place to start because we’re trying to get you back to becoming more physically active. So that’s really the best place, find what works for you right now so you can start in that process of becoming more physically active.
O’Brien: And I love that to becoming more physically active, it doesn’t necessarily mean exercise because we all look at exercise differently. And gardening is not easy.
Kelokates: No, it can take a lot of time. And it can be exhausting and tiring to the day, you’re doing a lot of movements. And I mean, I like gardening. So, definitely encourage that. I mean, I prefer exercise. But if that’s not what that person wants, well, then we need to find something that aligns with what I think they need, but what fits their values. And that, again, goes back to that collaborative process of, okay, I know what I think you need; how do we fit that into the lifestyle that you want to live?
O’Brien: Yeah, because if they’re not going to do it, then no one’s going to see improvement. So you want to make sure it’s something that a person is going to do and enjoy, hopefully.
All right, Sam, as we wrap up our conversation here, which has been so interesting and thoughtful, I’m curious if you have any final thoughts for our followers out there about utilizing physical therapy to help manage migraine?
Kelokates: I think one of the big things that I’ve come across over the last two years, trying to help people with migraine and other headache disorders, is that they’ve tried physical therapy before, and it didn’t work for them, or it made them feel a lot worse. And that’s really common, especially when you get a provider that doesn’t really understand headache disorders very well.
And when I came through PT school, I think we just learned about something called cervicogenic headache, where the neck pain was being referred into the head. And that can be misinterpreted for people with migraine, where they’re having neck pain that’s causing a headache. Well, that’s not the same thing, even though the neck is part of their problem. In that headache, the condition is a little bit different, and there’s more neurological involvement for somebody with migraine.
So even though you’ve gone to another provider, that doesn’t mean that they really understood your diagnosis. And if they were falling short in providing you good interventions because they didn’t understand the pathophysiology of what you were dealing with, that’s probably why they’re missing the mark and making it worse.
So you can always look for a new physical therapist. Each physiotherapist you see will not be treating in the same exact way as the person you previously saw. Just make sure that that person you feel safe and comfortable communicating with, and you feel like they are listening to you and your concerns during sessions.
O’Brien: That is absolutely such valuable advice because I think people dealing with chronic pain or health conditions, you get really discouraged, especially if you tried a treatment and it didn’t work. But try again. Especially dealing with the provider. You don’t know if the next provider is going to be like that.
Kelokates: Yeah, it’s true. It’s tough.
O’Brien: Well, that wraps up this episode of Spotlight on Migraine. I’d like to say a big thank you so much to our guest Sam Kelokates. Thank you so much for joining us and giving us all of your insight.
Kelokates: Thank you so much for having me, Molly. I appreciate it.
O’Brien: It was such a good conversation.
And to our followers out there, we really appreciate you following along. That wraps up this episode of Spotlight on Migraine. I’m Molly O’Brien, and we’ll see you next time.
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