Pediatric headache a very common issue says Victoria Karian, CPNP-PC

Headache and migraine are in the top 5 diagnoses presenting in the pediatric primary care office,” said Victoria Karian, CPNP-PC, a 42-year veteran of pediatric medicine. “Incidence of migraine in children is reported at 9-10%.”

Karian has worked at Boston Children’s Hospital for 25 years, with 12 years focus on inpatient pediatric pain and outpatient headache management. She is passionate about healthcare for children and adolescents.

Karian identified three most common subtypes of primary headaches seen in pediatric patients: migraine, tension-type and chronic daily headache.

In addition to the three “standout” conditions, there are migraine variants (a subsection of migraine) that affect a moderate amount of the pediatric population. These variants “very often transform into migraine headache by adulthood.”

Two of the most common variants are:

  • Abdominal migraine

This variant occurs “in about 12% of migraine patients.” Symptoms may include “moderate to severe stomach pain and/or nausea, rather than headache,” and duration of which “can last up to 72 hours.”

Karian noted, “Apart from the difference between pain location, symptoms are similar to migraine headache, including photophobia, phonophobia, nausea, vomiting, fatigue and pallor (pale appearance).”

Diagnostics (GI work ups) generally do not show any abnormalities. Patients tend to find relief and resolve abdominal migraine by taking an NSAID (such as ibuprofen).

A positive factor is that this variant “generally resolves by adulthood,” she stated.

  • Cyclic vomiting syndrome

This variant affects “3 to 5% of school-age children with migraine.”  Symptoms of it include “forceful and frequent vomiting, which can last for one or many days,” Karian said. It may also be accompanied by “abdominal pain and/or headache, plus photophobia, phonophobia, nausea, vomiting, fatigue and pallor.”

A very important note on this variant is the concern and likelihood of dehydration. Clearly it is very important to keep in firm communication with your doctor, urgent care or hospital should a child exhibit these symptoms and therefore, follow their guidance and medical advice.

In Karian’s experience and research, “Anxiety and stress are the most prevalent migraine and headache trigger.” It is frequently reported that “the onset of first migraine is in childhood or adolescence. Migraine and headache incidence has remained stable over the years.”

Her sound advice for children experiencing headache conditions and their guardians charged with making decisions on their behalf is to following a “healthy headache lifestyle.” It tends to be “the most effective way to decrease the frequency of all kinds of headache, including migraine. This includes enough sleep, healthy diet, lots of exercise, plenty of hydration, and stress management,” Karian said.

With a child or adolescent, the parent or guardian plays a pivotal role.  When asked if those in charge of children’s medical decisions are more on the proactive, preventive end of headache/migraine conditions or not, Karian explained as follows.

As with anything “There is a wide variety of behaviors and attitudes of parents when dealing with a pediatric headache diagnosis.” She finds a significant group of parents that “are happy to embrace the ‘healthy headache lifestyle’, working diligently on areas needing improvement.”

In addition to that she finds “Some parents are interested in trying lifestyle and also supplements, such as Magnesium or Riboflavin (vitamin B2). There are also some parents who prefer to start with daily headache medications.”

What’s great to hear is that in her experience, “most parents prefer to start by working on lifestyle. There can be significant improvement once there is understanding and awareness of what are the most helpful lifestyle practices. Parents can easily identify which lifestyle habits are most in need of improvement for their own child, and with support and guidance, they can provide that positive reinforcement for their child.”

These certainly have a strong likelihood of carrying forward with the child into adulthood. Having tools, resources, a positive support group and consistency can influence many to keep that a constant throughout their lifespan.

Let’s break down what is included in the “healthy headache lifestyle” Karian touched on. (This does not include medications.)

  • “Adequate sleep for age” i.e. regular sleep schedule all nights of the week;
  • “Learning what good sleep hygiene involves and getting off screens at least 1 hour before bed”;
  • “Healthy varied and regular diet is important for general health and for preventing headache and migraine.” This includes no meal skipping, cutting down on processed foods and sugar;
  • Exercise “to keep body and mind healthy. It can include sports, dance, playing with their pet.” This also aids as a stress management tool;
  • “Hydration is a huge factor in managing headache and migraine. People with these conditions need more hydration than others in general and to avoid headache pain.” Hydration should be increased “in summer heat or with vigorous exercise … electrolyte-rich fluids are useful at times of bad headache”;
  • With stress and anxiety topping the list for inducing headache and migraine, “stress management needs to be considered. Managing stress can include psychotherapy, cognitive behavioral therapy, keeping one’s schoolwork organized, engaging in creative pursuits.”

The recurrence of experts’ verbalizing the impact stress and anxiety has on our health just continues to be amplified. As Karian stated, “There is a strong correlation between anxiety/depression and pain/headache through neuropathway connections.”

It’s important for individuals of all ages to find tools, resources, and practices that can aid in lowering stress, calming the internal system.  “Anything that makes mood better can help with headache and vice versa,” said Karian.

When asked what she feels is the most under-represented condition, Karian stated in her specialty pediatric headache clinic it is one that terribly impacts teens. “Teens suffer the most, can become disabled, and generally do not benefit from standard medications.”

The condition is “new daily persistent headache … an uncommon headache, characterized by unrelenting headache, 24/7, often occurring out of the blue, and after a viral illness or possibly after too many concussions.” While more research is needed to provide further clarity, she said “it is thought to be a post-viral inflammatory condition.”

“More attention and research need to be paid to these patients, to figure out what can help, as this headache condition can last for years,” Karian explained.

It impacts “2-4% of patients with headache, and actually more common in adolescents than in other populations.”

Experiencing new daily persistent headache includes having “pain range from moderate to severe, along with symptoms like persistent nausea, dizziness, environmental sensitivities.” Simply stated, “It is a primary headache condition with characteristics of both tension-type headache and migraine,” Karian said.

With a strong dedication to the medical community, pediatric population, and striving to make a positive difference in all those lives she comes in contact with, Karian shared the following positive message for readers of The Honest Migraine.

“Commitment to a healthy life and healthy coping patterns can go a long way in reducing pain and suffering with headaches and migraine.”

Victoria Karian is a graduate of Boston College (BSN) and Simmons College (MSN). She also served in the US Peace Corps in Jamaica. She has 42 years of experience in pediatric medicine and has worked at Boston Children’s Hospital for 25 years, the past 12 in both inpatient pediatric pain and now primarily outpatient headache management in the Multidisciplinary Pediatric Headache program.

She recently authored a resource guide for pediatric primary care providers called, “Getting Ahead of Pediatric Headaches: A comprehensive guide for nurse practitioners to manage headaches in children and adolescents,” available on Amazon. She also is a preceptor of PNPs through Northeastern University. She has contributed to a variety of academic publications over the years. Vickie Karian started her blog ( in 2017, where she shares information and thoughts about caring for the pediatric population with chronic headaches.

Karian’s insight can make a noticeable difference in the health of your family and our communities.  

Coming next: How do you define ‘healthy?’  


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