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In a child who presents to the emergency department what are the clinical features that distinguish tension type headaches (TTH) from migraine?

Three Part Question

In [children who present to the emergency department] what are the [clinical features] of [migraine and tension type headaches].

Clinical Scenario

A 5 year old child comes to the emergency department accompanied by her mother. The child complains of a bilateral headache of moderate intensity which started 30 minutes ago and is still present. She has also vomited in the last 10 minutes. You wonder whether this patient has a migraine or a tension headache.

Search Strategy

Medline 1950-June 2007 using Ovid Interface
Embase 1980 to 2007 Week 24 using Ovid Interface
[(exp headache OR exp migraine OR exp migraine without aura OR exp migraine with aura OR exp migraine aura) AND (exp tension type OR exp tension headache OR pressure AND (exp symptoms OR exp clinical features OR migraine OR tension headache ) AND (LIMIT to children AND english)]

Search Outcome

39 papers were identified on Embase of which 2 were relevant and 25 papers were found on medline of which 2 were relevant.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Necdet Karli et al,
2387 children aged between 12-17 years.Multistep stratified cluster sampling method.Common features of migraine with/without aura.Nausea, vomiting, photophobia/phonophobia, osmophobia,Moderate to severe intensity found in 92.4%. Pulsating headache found in 79.2% of patients. Headache worsened by exercise.Some adolescents had features of both migraine and tension type headcahe, therefore making it difficult to make a firm diagnosis.
Trigger factors for migraine.Bright light, smoking, cigarette smoke odour, hunger, certain foods, changes in sleep pattern.
Common features of tension type headache.Bilateral location of pain in 91.3% of patients. Mild to moderate pain in 90.6% of patients. Heavy/tight quality pain.
Less common features of tension type headachesPulsating pain, photophobia, phonophobia, nausea and vomiting. Worsening of headache by routine exercise. Triggered by bright light or odour.
Features of tension type headaches in 12-14 year oldsPulsating pain, nausea, worsening of headache by exercise, photophobia, phonophobia.
Donald W.Lewis et al,
576 childrenReview using PUBMED and MEDLINEDuration of TTH5 to 30 minutes but may last >48 hours. 36.7% of children had headache that lasted less than 30 minutes.Location of the headache is often difficult for children to determine and describe, therefore results regarding the location of pain maybe inaccurate.
Quality of TTHPressing/tightening 74%. Pulsating 16%
Location of TTHHeadache was bilateral in 57-86% of patients.
Aggravating factors of TTH15% of patients noted that TTH was aggravated by routine physical activity.
Intensity of TTH75% reported mild-moderate intensity.
Features common to migraine than to TTHAbdominal pain, nausea, vomiting, vertigo, visual disturbance, sweating, using dark room for pain relief, all more common in migraine and less likely in TTH.
Features specific to TTHPressing/tightening pain, mild to moderate intensity, and lack of associated symptoms.
Features specific to migraineLocation of head pain and duration of headache.
Dr A Chakravarty,
8-15 year olds. 22 children in total, 4 with TTH and 3 with migraineQuestionnaireFeatures seen in migraineMigraine resembled chronic migraine as seen in adults but headache was bilateral in children. Past history of episodic pulsatile headache > 1 hour duration and bitemporal. Exacerbation by physical activity and reading. Mild nausea at times of pulsatile exacerbations. No vomiting. Nearly continuous dull tightening/heaviness with several pulsatile exacerbations during each headache lasting > 1 hour.Conclusions were drawn on the basis of 4 children diagnosed with TTH and 3 children diagnosed with migraine. Sample size was too small to make a firm conclusion.
Features seen in TTHTTH resembled chronic TTH in adults. Past history of occasional episodic TTH (2 cases experienced < 10 episodes in 1-2 years). No nausea, photophobia or phonophobia. Exacerbation of TTH with reading.
Umberto Balottin et al,
35 children aged 12 months to 6 years.Prospective longitudinal evaluationNumber of children with migraine and TTH.10 children diagnosed with migraine and 16 children diagnosed with TTH (using ICHD).There was partial/absolute disagreement between the intuitive clinical diagnosis and the IHS-criteria based diagnosis due to childs inability to describe features of the headache, failure to meet criteria for minimum duration and presence of migraine like symptoms in some patients with tension headache.
Number of headachesIndividuals with migraine had 5 episodes and those with TTH had 10 episodes.
Features seen in patients with migraine without aura.Bilateral headache 6/10. Throbbing pain 6/10. Pain <2 hours 8/10. Pain 2-48 hours 2/10. Photophobia and phonophobia 6/10. Nausea or vomiting 6/10.
Features of TTH seen in patientsPain was pressing/tightening in 9/16. Pain was <30 minutes 8/16. Nausea 3/16. Vomiting 2/16.


Two of the studies used a large sample size whereas the remaining two used a small sample size.

Clinical Bottom Line

The severity, character, and duration of pain differentiates TTH from migraine. The severity of pain in TTH was reported to be mild to moderate and pain was described as pressing/ tightening. Duration of pain was between 5-30 minutes though this could last up to 48 hours in a minority of patients. There was no prodromal symptoms and photophobia and phonophobia were absent in TTH. Few patients experienced associated symptoms such as nausea and vomiting but no trigger factors were identified. Therefore the severity of pain, character and duration of pain, absence of prodromal symptoms, phonophobia, photophobia and trigger factors maybe enough to make a diagnosis of TTH rather than a diagnosis of migraine.


  1. Necdet Karlý, Semra Akgöz, Mehmet Zarifoðlu, Nalan Akýþ, Sevda Erer. Clinical Characteristics of Tension-Type Headache and Migraine in Adolescents: A Student-Based Study. Headache: The Journal of Head and Face Pain 399–412, 2006
  2. Donald W. Lewis, Yeisid F. Gozzo and Marc T.Avner. The "Other" Primary Headaches in Children and Adolescents. Pediatric neurology 303-313, 2005
  3. A Chakravarty. Chronic daily headache in children and adolescents: a clinic based study from India. Cephalalgia 795-800, 2005 October
  4. Umberto Balottin, Francesca Nicoli, Giovanni Pitillo, Oreste Ferrari Ginevra,Renato Borgatti, Giovanni Lanzi d. Migraine and tension headache in children under 6 years of age. European Journal of Pain 307–314, 2004 August