"My Head Hurts" — Three Clues for Distinguishing Migraine, Tension, and Orthostatic Headache at Home

Lead

"My head hurts" is one of the most common complaints in school-age children. Combined estimates across primary and middle school populations put the prevalence of migraine at roughly 11% and tension-type headache at around 17% [1,2]. In a typical classroom, several children are likely dealing with recurring headaches.

Yet parental responses tend toward one of two extremes. Either "Is this just an excuse to skip school?" or "Could there be something seriously wrong with the brain?" Neither reaction is entirely unreasonable — but there is a large space between them worth understanding. Knowing the main headache types, and keeping one set of warning signs in mind, makes it much easier to choose an appropriate response.

Background: Prevalence and Diagnostic Framework

Recurring headaches in school-age children are not rare. A meta-analysis by Abu-Arafeh et al. (2010) found lifetime headache rates of 58% or more in children and adolescents, with migraine at 11% and tension-type headache at 17% — figures that have been consistently reproduced [2,3]. A 2025 global disease burden study estimated that approximately 550 million children and adolescents worldwide had headache disorders as of 2021 [8].

The International Headache Society's diagnostic classification (ICHD-3) sets the duration of migraine in children at 2–72 hours — shorter than the adult criterion of 4–72 hours [4]. This is one reason pediatric headache can be diagnostically tricky.

Secondary headaches — those caused by an underlying structural condition such as a brain tumor or meningitis — account for only a few percent of all headaches, but the consequences of missing them are serious. That is why recognizing the warning signs described below matters.

Three Types of Headache

Migraine: What Looks Different in Children

Adult migraine is strongly associated with one-sided, pulsating pain — but in school-age children, pain is often bilateral and concentrated at the front of the head [4,5]. Duration tends to be shorter, sometimes ending within one to a few hours.

Prominent accompanying features include vomiting, which can be conspicuous enough that the headache is barely mentioned. A variant called abdominal migraine involves repeated vomiting without a strong pain complaint and can require differentiation from functional abdominal pain [6]. Sensitivity to light and sound (wanting a dark, quiet room), worsening with movement, and relief when lying down are typical patterns.

Family history is useful clinical information. When a parent or grandparent has migraine, the same pattern often appears in the child.

Visual aura (such as flickering zigzag lights) is less common in school-age children than in adults; the absence of aura does not rule out migraine.

Tension-Type Headache and Orthostatic Headache

Tension-type headache is described as a tight, pressing sensation — not a throb. It is usually bilateral, and unlike migraine, it is not made worse by ordinary physical activity. Nausea and vomiting are typically absent.

The pattern of headache that starts reliably just before school — or on school days and not on weekends — frequently represents stress-triggered tension-type headache. Many moments where a parent wonders "is this faked?" fall into this category. That said, "stress is the cause" does not mean the pain is imaginary. The pain is real. The stress in the background (peer relationships, academic pressure) is worth exploring rather than dismissing.

Orthostatic headache (associated with orthostatic dysregulation, or OD) is characterized by being worst in the morning, worsening immediately on standing, and improving when lying down. The typical picture is a child who reports headache at morning assembly or on the way to school and is relatively better by afternoon. This pattern warrants evaluation for OD, which sometimes requires formal assessment at a pediatric clinic.

Red Flags for Secondary Headache

The following signs should prompt consideration of a medical consultation [7]:

• Thunderclap headache: "The worst headache of my life, starting suddenly"
• Fever combined with neck stiffness (neck feels rigid, chin cannot reach the chest): may suggest meningitis
• Headache that changes with position (worsens when bending forward): may indicate elevated intracranial pressure
• Headache accompanied by visual disturbances, limb weakness, or speech changes
• Pain severe enough to wake the child from sleep
• Headache that is consistently worst in the morning, especially with vomiting: may suggest elevated intracranial pressure (though a similar pattern also occurs with migraine)
• Headache following a recent head injury or trauma

Any one of these is sufficient reason to make "consult a clinician soon" the default next step.

Recording Helps Diagnosis

In headache care, a written record is a practical diagnostic tool. Noting "when it started, how long it lasted, what the pain felt like, what was happening at the time, and what helped" — even informally — significantly enriches the information available at a first appointment.

Such records also help distinguish between migraine, tension-type, and orthostatic headache. Patterns like "headache only on Monday mornings" or "no pain on days without school" become visible only through accumulation over time. Keeping a headache log in a childcare-tracking app is one of the least expensive and most sustainable forms of diagnostic support available to families.

Practical Takeaways

• If headaches recur more than twice a month, start a headache diary. Date, time, duration, pain intensity (1–10), circumstances, associated symptoms, any medication taken and its effect. A week of entries dramatically improves the information density at a first visit.

• Memorize one red flag. Even just "sudden maximum-intensity headache (thunderclap)" and "fever plus neck stiffness" is enough to identify genuine urgency.

• If the pattern looks migrainous — light avoidance, sound avoidance, wanting to lie down — act early. Over-the-counter analgesics (acetaminophen, ibuprofen) are more effective when taken at the onset. Waiting for the pain to peak before medicating makes them less effective.

Summary

Children's headaches don't fit a simple binary of "faking it" or "something seriously wrong." There is a rich differential in between. Knowing the three main types — migraine, tension-type, and orthostatic — and keeping one set of warning signs in mind opens up responses beyond dismissing or over-worrying. Recording is the cheapest tool for improving diagnostic accuracy. Once headaches are recurring, starting a log is the single step that expands all the options that follow.

References

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2. Abu-Arafeh I, et al. Prevalence of headache and migraine in children and adolescents: a systematic review of population-based studies. Dev Med Child Neurol. 2010;52(12):1088–1097. doi:10.1111/j.1469-8749.2010.03793.x. PMID: 20875042.
3. Wöber-Bingöl Ç. Epidemiology of migraine and headache in children and adolescents. Curr Pain Headache Rep. 2013;17(6):341. doi:10.1007/s11916-013-0341-z. PMID: 23615952.
4. Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition. Cephalalgia. 2018;38(1):1–211. doi:10.1177/0333102417738202. PMID: 29368949.
5. Hershey AD, et al. Pediatric migraine: a comprehensive review. Curr Neurol Neurosci Rep. 2023. PMC: PMC10277668.
6. Lewis DW, et al. Symptoms of migraine in the paediatric population by age group. Cephalalgia. 2008;28(10):1048–1053. doi:10.1111/j.1468-2982.2008.01661.x. PMID: 18727643.
7. Özge A, et al. Overview of diagnosis and management of paediatric headache. Part I: diagnosis. J Headache Pain. 2011;12(1):13–23. doi:10.1007/s10194-011-0297-5. PMC: PMC3056001.
8. Hao N, et al. Global epidemiology and burden of headache disorders in children and adolescents from 1990 to 2021. J Headache Pain. 2025. doi:10.1186/s10194-025-02017-7. PMID: 40172214.
9. Gelfand AA, Goadsby PJ. Pediatric migraine — epidemiology, diagnosis, and treatment. Semin Pediatr Neurol. 2016;23(1):34–43. doi:10.1016/j.spen.2016.01.002. PMC: PMC2778404.