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 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.

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!