In a child who presents to the emergency department what are the clinical features that distinguish tension type headaches (TTH) from migraine?
Date First Published:
July 9, 2007
Last Updated:
July 18, 2007
Report by:
Shabnam Rashid, Medical Student (Manchester Royal Infirmary)
Search checked by:
Kevin Mackway-Jones, Manchester Royal Infirmary
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
Embase 1980 to 2007 Week 24 using Ovid Interface
Search Details:
[(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 headache.mp.) AND (exp symptoms OR exp clinical features OR migraine symptoms.mp. OR tension headache symptoms.mp. ) AND (LIMIT to children AND english)]
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):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Clinical Characteristics of Tension-Type Headache and Migraine in Adolescents: A Student-Based Study. Necdet Karlý, Semra Akgöz, Mehmet Zarifoðlu, Nalan Akýþ, Sevda Erer. 2006 Turkey | 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 headaches | Pulsating 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 olds | Pulsating pain, nausea, worsening of headache by exercise, photophobia, phonophobia. | ||||
| The "Other" Primary Headaches in Children and Adolescents. Donald W. Lewis, Yeisid F. Gozzo and Marc T.Avner. 2005 Virginia | 576 children | Review using PUBMED and MEDLINE | Duration of TTH | 5 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 TTH | Pressing/tightening 74%. Pulsating 16% | ||||
| Location of TTH | Headache was bilateral in 57-86% of patients. | ||||
| Aggravating factors of TTH | 15% of patients noted that TTH was aggravated by routine physical activity. | ||||
| Intensity of TTH | 75% reported mild-moderate intensity. | ||||
| Features common to migraine than to TTH | Abdominal 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 TTH | Pressing/tightening pain, mild to moderate intensity, and lack of associated symptoms. | ||||
| Features specific to migraine | Location of head pain and duration of headache. | ||||
| Chronic daily headache in children and adolescents: a clinic based study from India. A Chakravarty. 2005 India | 8-15 year olds. 22 children in total, 4 with TTH and 3 with migraine | Questionnaire | Features seen in migraine | Migraine 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 TTH | TTH 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. | ||||
| Migraine and tension headache in children under 6 years of age. Umberto Balottin, Francesca Nicoli, Giovanni Pitillo, Oreste Ferrari Ginevra,Renato Borgatti, Giovanni Lanzi d. 2004 Italy | 35 children aged 12 months to 6 years. | Prospective longitudinal evaluation | Number 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 headaches | Individuals 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 patients | Pain was pressing/tightening in 9/16. Pain was <30 minutes 8/16. Nausea 3/16. Vomiting 2/16. |
Author Commentary:
Two of the studies used a large sample size whereas the remaining two used a small sample size.
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.
References:
- Necdet Karlý, Semra Akgöz, Mehmet Zarifoðlu, Nalan Akýþ, Sevda Erer.. Clinical Characteristics of Tension-Type Headache and Migraine in Adolescents: A Student-Based Study.
- Donald W. Lewis, Yeisid F. Gozzo and Marc T.Avner.. The "Other" Primary Headaches in Children and Adolescents.
- A Chakravarty.. Chronic daily headache in children and adolescents: a clinic based study from India.
- 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.