All about the Migraine…. part 3

In the previous post, I talked about the important lifestyle factors and strategies of hydration, diet and sleep. In this post I will discuss exercise/physical activity.  Again these are basic lifestyle strategies that are appropriate for all headaches, but can be particularly important to migraineurs.

Exercise or physical activity is vital to healthy functioning for everyone.  For some of our patients, it can be challenging to get active.  And if you have a migraine, the last thing you want to do is exercise.  But getting exercise on a regular basis is an excellent way to prevent migraines. It physiologically improves your cardiovascular system, provides stress relief and releases endorphins, and when done with others, exercise can be a positive social experience. All of these aspects contribute to a healthier lifestyle with fewer migraines.

Our basic recommendation is 30 minutes of vigorous activity, 3 times per week. This can be sports practice or games, dance class, going to the gym or a run, or playing outside with the family dog. Kids can be encouraged to make the active choice.  That can mean taking the stairs instead of the elevator, walking up and down every aisle at the grocery store, or parking (or encouraging their parent) the car far away from the store entrance to sneak in some extra steps.  We all need more exercise, and the more the family participates, the easier it is for the teen to join in. No teen wants to be the one who is singled out for exercise.  Families or friends can get activity monitors and set up challenges- see who can get the most steps in a day, weekend or the whole week. There are endless possibilities and options. The key is to just get started.

For those kids who are inactive, this might seem daunting. They may have stopped doing their sports or activities because of migraines, and are worried that activity will make them worse. This is a situation where pacing is really helpful. Basically activity pacing is the slow return to exercise, working toward being able to tolerate increased intensity and time in a vigorous activity. Often, I will ask a teen to start to get more active and describe how to do it, slowly and methodically. On the next visit, he report that they ran a mile once, had worse headaches and stopped.  (Not exactly what I recommended!)  It’s a hard concept to explain. I found some excellent You Tube videos, done by a teen girl with chronic pain, with great explanations.  The series of 5 videos is called Pacing: Your Superpower against chronic pain, and here’s the link:  YouTube videos on activity pacing.  I encourage my patients to check them out and while not every suggestion will apply to them, they can gain better understanding of the concept and make an appropriate plan for themselves.

One of the keys to establishing an exercise habit is convenience. Whatever activity is chosen, participation has to be easy to achieve: going to a neighborhood gym rather than the one across town; walking around the block or to and from school; carpooling with a friend to exercise/dance class, etc.  The strategy of convenience makes it easier to establish and keep a good habit, and then it just becomes a part of daily life. (Read more about strategies for establishing good habits in the book “Better Than Before” by Gretchen Rubin.)

Finally, I am always asked about what is the best exercise to do.  My answer is always the same: Do the activity that you like and that you will actually do.  Of course, there are a few things to avoid, like doing inversions in yoga during a migraine.  And I am biased against high impact sports, where it is more likely to result in concussion (a potential disaster for migraineurs).  But any activity that brings you joy, satisfaction, a good feeling, a hit of endorphins, is the right exercise.  Just put the phone down and get moving!

All about the Migraine….part 2

So you have identified one of your patients as having migraine. Now decisions have to be made about management. Important points to consider are: frequency of migraine, intensity of pain and/or associated symptoms, triggers, and lifestyle factors.  Unless the patient is presenting with frequent or intractable migraine several times/week, the first things to review with the patient and family are basic headache-healthy lifestyle guidelines.

What are the most important lifestyle factors to consider in migraine (or any headache for that matter)? Hydration, diet, sleep, exercise/activity, and stress management.  Helping families understand what they can do to reduce migraine is empowering and creates a sense of partnership.  Some families may want to go straight to daily preventive medications, but most would rather start with the basics.

Suggested recommendations:

Hydration is probably the most important aspect of preventing migraine in kids and teens.  I usually recommend that patients drink the equivalent of their weight in kilograms (50kg = 50 oz), or half their weight in pounds (100lbs = 50 oz). This works for patients up to 80kg; above that weight, I will recommend 80-100oz/day.  I have found that families need a real number to aim for, rather than just saying to ‘drink more’, which greatly improves compliance.  I strongly encourage bringing a refillable water bottle to school daily, and bringing it home empty. Most bottles are 20-24oz, and kids who drink during school generally meet their hydration requirements.  Appropriate hydration includes water, seltzer, electrolyte-rich fluids, milk, juice, and do not include caffeinated beverages or soda. Neither sugary nor sugar-free sodas are great, because both high sugar and artificial sweeteners are migraine triggers. If the kids balk at water, a little juice added can help. Some schools do not allow water bottles, but a note from a provider will help (or it can be a part of a 504 education support plan).  I encourage using electrolyte-rich fluids around heavy athletic activity or during migraine, but not as a daily beverage- can lead to obesity or dental caries due to sugar.

Diet is important in a variety of ways.  For some migraineurs, there are foods that can trigger migraines and need to be identified and avoided. There are lists of these foods readily available and I will attach a list here (Headache Elimination Diet).  I tell kids that as a person with migraine, they have to be a detective for their triggers, again empowering them to have agency in their own health. In addition, ensuring regular meals- breakfast, lunch and dinner plus snacks- is key in preventing migraine.  Meal skipping can trigger migraine and many patients have learned this the hard way. Also a diet as varied and nutritious as possible is just good for health.  Some children are very selective (‘picky’), and can be lacking in essential nutrients.  Kids who eat a ‘beige’ diet, eating few if any vegetables or fruits, probably would benefit from a multivitamin.  A common migraine supplement is vitamin B2 (riboflavin) and children with limited diets would benefit from a B complex vitamin.

Getting enough sleep is crucial in the prevention of migraine.  Depending on their age, children and teens need between 8-12hours of sleep per night.  In addition to getting to bed on time, using good sleep hygiene, including bedtime routines and managing time on electronics, is key to adequate sleep.  In our busy, over-scheduled lives, prioritizing sleep can be difficult.  Families just need to understand how inadequate sleep can affect the migraineur.  This might mean that the tween avoids sleepovers, as she knows that a migraine is likely the next day. Or that strict limits on electronics- using phone, tablet, video games, etc- are consistent and enforced. There are many barriers to getting enough sleep, including heavy homework loads, multiple sports or other activities, as well as early start times for high school.  Many communities are beginning to address the start time issue, but families are encouraged to be proactive in setting limits on participation in activities. Inadequate or disrupted sleep is a common migraine trigger.

I’ll continue to review lifestyle factors in the next post. Most of the recommendations apply to all headache types for the most part and are worth a discussion with all families.

All about the Migraine…. part 1

The 3 most common subtypes of primary headaches commonly seen in pediatric patients are: migraine, tension-type, and new daily persistent headache. Children often have a combination of types, such as chronic mixed type headache, which generally combine migraine and tension-type headache. All primary headaches present differently and are often treated differently.  Migraine is a well-known type of headache, so I will cover that first, in a number of posts.  There are also migraine variants,  particular to children, such as abdominal migraine and cyclic vomiting syndrome.

Migraine is a neurologic disorder, characterized by headache attacks. Headaches are episodic or chronic, are recurrent, can last from 4-72 hours, with moderate to severe throbbing pain. Migraine pain occurs due to dilation and inflammation of the intracranial blood vessels, which irritates the adjacent nerves.  Pain can be felt in one location, such as behind the eyes or temples, or one-sided, or everywhere (holocephalic). Pain can occur suddenly or be preceded by warning symptoms, called an aura.  Along with head pain, patients can experience nausea and/or vomiting, photophobia, phonophobia, osmophobia (sensitivity to smell), pallor, lightheadedness or dizziness, visual changes (blurred vision, loss of vision, seeing colors), hearing changes (tinnitus), paresthesias, focal numbness, fatigue, sweating, and scalp sensitivity (allodynia). The only constant in migraine is that every migraine patient experiences their migraines differently- different location, constellation of symptoms, triggers.  Diagnosis is made based on symptoms and history and in the majority of cases, migraine is clearly identified.

Migraine is often found within families, passed genetically through generations.  The incidence is more common in women (17%) than men (6%). Most people have their first migraine between the ages of 6 and 25 years, so it is likely that their pediatric provider will be the first person to evaluate for migraine. Imaging is not required to diagnose migraine, especially if there is a strong family history.  However, imaging (MRI) can be helpful for presentations without family history, unusual, complex or variant-like symptoms. Most families are comfortable without imaging when there is family history of migraine.

Most migraineurs have missed school, social or sports activities, or work during a migraine, and about 50% have difficulty functioning at all during an attack. As you can imagine, having 1 migraine episode per week and having to miss 1 day/week of school, is going to have significant consequences.

The next step, after making the diagnosis, is to decide on a treatment plan.  Does this patient need a preventive or daily medication? What is the rescue plan? And even more importantly, what about the lifestyle factors that can trigger migraine or reduce the incidence of migraine?  We will start to cover this topic in my next post.

Headaches in the community

Headache is one of the most common problems seen in the primary care office. It is often a chronic complaint, not easily managed, and often an unsatisfying experience for families and providers.  You can’t cure headache like an ear infection, it will always come back in some form or another.  And while headache is technically a neurological problem, at its heart, headache is a chronic pain problem. It is not as glamorous or interesting as many neurological conditions. Many neurologists are not as interested in headache as they are in other conditions. Patients and families are often challenging and the issues are often multi-factorial, comprehensive and complicated.  Chronic pain is a field that takes a certain mindset and approach, not for the faint-hearted. I believe that a multidisciplinary wellness approach to care is best, and our job is to guide the families to adopt that approach.  This is time consuming, requiring a lot of counselling and coaching, to achieve good results, and most importantly to prevent disability.

Fortunately, for those of us who work in the headache field, there are many wonderful patients and families, more than happy to work as a team to achieve good results. You can have your chronic migraine patient with several comorbidities including inadequately treated psychiatric issues and significant disability as your first patient of the day. Then you can have a patient with episodic migraine or menstrual migraine, with many family members with migraine, has learned their triggers, has a rescue plan, and is doing well overall. It’s really a mixed bag in the headache world, which makes it a bit different than the usual chronic pain patients, especially in pediatrics. It is also more enjoyable.

I think the most important thing is being able to accurately make the diagnosis, identify appropriate treatment, and obtain buy-in from the patients and families to accept the multidisciplinary approach to care.  Since I work in a tertiary care outpatient clinic setting, our patients have already been evaluated, tried some medications or treatments, and have not had success. Patients may have had inadequate medication trials, been given incorrect diagnoses and treatments, and establishing trust is difficult. In these days, instant gratification is desired, and this is just NOT a hallmark of headache care. Daily medications can take a month to see effectiveness (or not). Lifestyle changes take time.  Learning cognitive behavioral skills take a while to become effective.  Establishing a healthy headache lifestyle along with adequate treatment options is a marathon, not a sprint. There’s a lot of trial and error.  Without the families’ trust, this journey is made even more difficult.

For the community provider, having some good baseline knowledge of headache, is a great starting point.  In the next posts, I will review the primary headache in pediatrics. Learning to recognize the specific headaches and common treatments, both preventive and rescue, is the bread and butter of headache medicine.


I have a headache!


So your young teenage patient comes in the office with a primary complaint of headache. This is something that happens very frequently.  In fact, headache is in the top 5 diagnoses for children and teens, occurring in 75% of teens and 25% of younger children.  Kids miss school, lose time with friends and in activities.  Family life can be significantly disrupted by headaches.  Everyone in the family has decreased quality of life, and concurrently increased environmental stress.

And with this complaint, there are many things to think about. Is this a primary headache, such as migraine, tension-type, or new daily persistent headache? Is this a secondary headache, such as a headache caused by something serious (brain tumor, brain bleed or meningitis), or less serious (allergies, sinus infection, virus)? Is this the first time your patient has complained of headache or the 20th time? Are there any pre-existing comorbid conditions?   The most important thing is to distinguish between primary and secondary headaches, and then go from there.  You absolutely don’t want to miss that secondary headache diagnosis.

You decide that your patient is constitutionally well, has no signs of serious illness, injury, or viral infection. This is most likely a primary headache. And now the fun begins!

Being a provider for patients with headaches is like being a detective. And it helps if your patients and families join you in your detective work.   I always talk with families about their role, especially with data collection, because good data helps guide care and interventions.  It also encourages the partnership between provider and family, building that relationship.

One of the hardest things about being a headache patient is that it’s an invisible affliction.  Nothing is more important to a headache patient than having a provider who understands, is supportive and knowledgeable about their health issues. It’s the ultimate key to improvement in health outcomes and lifestyle changes.

Welcome to the HeadFirst PNP blog

Hi, my name is Vickie and I am a PNP working in pediatric headache/pain medicine for the past 10+ years.  I’ve been a nurse for 37 years and a PNP for 21 years, so I have plenty of experience under my belt.  I’ve started this blog to share some information and insights I have gained over the years, with other providers and colleagues.

Headaches are one of the most common reasons that patients visit their pediatricians. There is a lot of information out there about headaches, most of it geared to adults.  I looked around the blogosphere and only found blogs about headaches/migraines by people who suffer with headaches, particularly migraineurs.  While many of these blogs are interesting, none really looked at the headache world from a provider’s perspective.  So I decided to create my own information stream, sharing helpful guidelines and strategies, up and coming research initiatives, and personal insights.

Headaches in children and teens are different from those in adults. There are many reasons why, such as genetics, biological, psychological and sociological factors, school and environmental factors.  What I do know is that headaches are a source of frequent school absence, family disruption and unnecessary pain.  By sharing my thoughts and ideas, I hope to improve the lives of both our patients/families and those who so diligently care for them.

Join me for a ride on the headache rollercoaster!