Headache is one of the most common neurological symptoms in children and adolescents and is among the leading causes of pediatric neurology referrals [1]. Tension-type headache (TTH) and migraine are classified as primary headaches by the International Headache Society (IHS) and are among the most common types of headaches in the pediatric population [2]. Although it varies depending on the design of the studies, the average prevalence of TTH in children and adolescents has been reported as 17%, while that of migraine has been reported as 11% [3]. The etiopathogenesis of TTH and migraine is not fully understood, and it is thought that numerous genetic and environmental factors may play a role. Psychiatric disorders, particularly depression and anxiety disorders, frequently co-occur with TTH and migraine. However, it is not fully understood whether psychiatric disorders trigger TTH and migraine, or whether TTH and migraine trigger psychiatric disorders.

There are many studies examining the relationship between headaches and psychiatric disorders. For example, a recent study showed that 39.7% of children and adolescents diagnosed with headaches also had at least one psychiatric disorder. This study indicated that the most common psychiatric disorders were anxiety disorders and depressive disorders [4]. Another recent study has indicated that depression, generalized anxiety disorder (GAD), and social anxiety disorder are significantly more common in adolescents diagnosed with migraine [5]. Similarly, high levels of anxiety and depression symptoms have been reported in individuals diagnosed with TTH [6]. Studies comparing psychiatric symptoms in individuals diagnosed with migraine and TTH have reported inconsistent results. Some studies suggest that children and adolescents with migraine experience more anxiety, depression, and social functioning problems [7,8], while others report that individuals diagnosed with TTH have more difficulty recognizing, understanding, and expressing their emotions and exhibit more pronounced symptoms of anxiety and depression [9,10]. Focusing on temperament and emotion regulation, which are considered relatively stable trait-like psychological characteristics, rather than on psychiatric disorders such as anxiety and depression that often emerge later and may fluctuate over time, may provide a clearer framework for understanding the associations between migraine, TTH, and psychiatric symptoms. Emotion regulation describes the process by which an individual controls or regulates their behavior in response to intense emotional states [11]. Pain, including headache, is an experience that encompasses both sensory and emotional components, and research has shown that emotion regulation processes may influence both of these dimensions [12]. Although there are studies investigating the relationship between headache and emotion regulation in adults, research on this relationship in children and adolescents remains quite limited. One study reported that adolescents diagnosed with migraine experienced significantly greater difficulties in emotion regulation compared to their healthy peers [7]. On the other hand, some studies have suggested that there is no significant relationship between emotion regulation characteristics and migraine [11,13]. These inconsistent findings may be related to differences in sample characteristics such as age range and clinical versus community samples, as well as variations in methodological approaches and the assessment tools used to measure emotion regulation. Cultural factors and differences in headache severity or chronicity may also contribute to these discrepancies. In the literature, there is only one study examining the relationship between emotion regulation and TTH in children and adolescents, which suggests that those diagnosed with TTH experience greater difficulties in identifying emotions compared to healthy controls [13].

Temperament is defined as a heritable trait that shapes an individual’s emotional and behavioral responses to environmental stimuli, and may be associated with headache and psychiatric disorders [14]. Temperament can influence an individual’s response to stress and psychological resilience; therefore, it is thought that temperament traits may be associated with stress-related symptoms such as headaches [15]. Studies investigating the relationship between headaches and temperament traits in children and adolescents are quite limited. Existing data suggest that children diagnosed with headaches may have temperament traits that make them more sensitive to environmental stimuli and more prone to negative emotions [16]. Individuals diagnosed with TTH have been reported to have higher levels of emotionality and shyness and lower levels of liveliness as temperamental traits [17]. In children diagnosed with migraine, it has been shown that they have lower self-control skills and tend to avoid harm [18]. There is only one study comparing the two primary headache groups in terms of temperament, in which the researchers found that patients with TTH had higher scores in emotionality and shyness, and lower scores in sociability compared to patients with migraine [19].

Despite the growing body of research on psychiatric comorbidities in pediatric headache disorders, studies directly comparing migraine and TTH in pediatric populations in terms of emotion regulation and temperament characteristics remain scarce. Moreover, research examining these relatively stable psychological dimensions simultaneously across migraine, TTH, and healthy control groups in children and adolescents is very limited. Clarifying whether distinct or shared profiles of emotion regulation difficulties and temperament traits characterize these primary headache types may contribute to a better understanding of their psychological correlates beyond secondary psychiatric symptoms. Accordingly, the present study aimed to compare emotion regulation skills and temperament characteristics among children and adolescents diagnosed with migraine, TTH, and healthy controls, while also examining differences in depressive and anxiety symptom severity across these groups. We hypothesized that both migraine and TTH groups would demonstrate greater difficulties in emotion regulation and distinct temperament profiles compared to healthy controls, and would exhibit higher levels of depressive and anxiety symptoms. Additionally, we explored whether potential differences between migraine and TTH groups would emerge in these psychological dimensions.

In the migraine group, 4 out of 49 patients were excluded (2 due to refusal to participate and 2 for not completing the questionnaires), resulting in a final sample of 45 participants (30 females, 15 males). In the TTH group, 3 out of 45 patients were excluded (1 due to refusal to participate and 2 for not completing the questionnaires), yielding 42 participants (31 females, 11 males). Among the 50 eligible individuals for the control group, 6 were excluded (4 due to refusal to participate and 2 for not completing the questionnaires), resulting in a final control sample of 44 participants. The flow of participants through the study, including eligibility assessment, exclusions, and final inclusion in the analysis, is shown in Figure 1. No significant difference was found among the groups in terms of sex distribution (p=0.585). However, the mean age of the migraine group (14.09±2.36 years) was significantly higher than that of both the TTH group (12.38±2.71 years) and the control group (12.70±2.36 years) (p=0.005 and p=0.026, respectively). High and very high income levels were found to be significantly higher in the control group compared to the migraine and TTH groups (p<0.001 and p<0.001, respectively), while low income levels were found to be higher in the TTH group compared to the control group (p<0.001). Mothers’ educational level was significantly lower in the migraine and TTH groups compared to the control group (p<0.001 and p<0.001, respectively), while fathers’ educational level was significantly lower in the TTH group compared to the control group (p=0.024). The sociodemographic data of the groups are summarized in Table 1.

EATQ-R surgency scores were found to be statistically significantly lower in the migraine group and TTH group compared to the control group (p=0.037 and p=0.010, respectively). EATQ-R effortful control scores were also found to be statistically significantly lower in the migraine group and TTH group compared to the control group (p=0.003 and p<0.001, respectively). Affiliativeness scores were found to be significantly lower only in the migraine group compared to the control group (p=0.011). On the DERS scale, goals subscale scores were significantly higher in the migraine group compared to both the TTH and control groups (p=0.035 and p<0.001, respectively). Additionally, impulse and strategies subscale scores of the DERS were significantly higher in the migraine group compared to the control group (p=0.009 and p=0.006, respectively). DERS clarity and non-acceptance subscale scores were found to show no significant differences between the groups. Among the R-CADS subscales, separation anxiety disorder (SAD) scores were significantly higher in the TTH group compared to the control group (p=0.016). Obsessive-compulsive disorder (OCD) scores were significantly higher in the migraine group compared to both the TTH and control groups (p=0.038 and p=0.017, respectively). Panic disorder (PD), GAD, and major depressive disorder (MDD) scores were also higher in the migraine group compared to the control group (p=0.017, p=0.030, and p<0.001, respectively). However, social phobia (SP) scores did not differ significantly between the groups. The scale scores and statistical analysis results for the groups are presented in Table 2.

Since significant differences were found between the groups in terms of age, parental education level, and family income, it was aimed to examine whether the relationships between the groups changed after controlling for these variables. For this purpose, MANCOVA analysis was applied by controlling for age, parents’ educational level, family economic level, and sex. According to the analysis results, the group variable was found to have a statistically significant multiple effect on the dependent variables (Pillai’s Trace V=0.329, F(28, 222)=1.560, p=0.042, η²=0.164). Based on these findings, an ANCOVA analysis was performed.

In the ANCOVA analysis, age, sex, parents’ educational level, and family economic level were defined as covariates, and according to the analysis results, significant differences were found in the EATQ-R subscales of effortful control, the DERS subscales of goals and strategies, and the R-CADS subscales of MDD scores. Post hoc analyses revealed that effortful control scores remained significantly lower in the TTH group compared to the control group (p=0.018), but the difference between the migraine group and the control group lost its significance. Additionally, the differences between the groups in surgency and affiliativeness scores were found to lose statistical significance. However, the goals and strategies subscale scores of the DERS remained significantly higher in the migraine group compared to the control group (p=0.007 and p=0.034, respectively). In contrast, the previously significant difference in impulse scores was no longer observed. Finally, when R-CADS scores were examined, the significantly higher MDD scores in the migraine group compared to the control group remained significant (p=0.010), whereas the significant elevation in the TTH group was no longer present. Moreover, all previously significant associations for SAD, OCD, PD, and GAD scores were found to have disappeared. The results of the ANCOVA analyses are presented in Table 3.

In this study, the emotion regulation skills and temperament characteristics of children and adolescents diagnosed with migraine and TTH were compared with those of a healthy control group. Compared to the control group, participants in the migraine group exhibited significantly greater impairments in sustaining goal-directed behavior (goals) and developing effective coping strategies (strategies), as well as significantly higher scores on the MDD. On the other hand, the TTH group demonstrated significantly lower effortful control scores, a temperament dimension related to attention and self-regulation. No significant differences were found between the migraine and TTH groups in terms of emotion regulation skills and temperament characteristics. These findings suggest that migraine and TTH in childhood and adolescence may be associated not only with depressive symptoms but also with relatively stable psychological characteristics such as emotion regulation abilities and temperament traits. Rather than implying causality, the results may reflect shared vulnerability patterns in children with primary headache disorders.

After controlling for age, sex, parental education level, and socioeconomic status, effortful control scores remained significantly lower in children diagnosed with TTH compared to healthy controls. Effortful control refers to self-regulation capacities such as sustaining attention, planning behavior, and inhibiting impulsive responses, and it represents an important developmental resource for psychological adjustment [20,26]. Deficits in this temperament dimension have been associated with increased vulnerability to various psychiatric disorders, including depression, anxiety disorders, attention-deficit/hyperactivity disorder, and conduct disorder [27-29]. Our findings indicate that this temperament dimension, which is closely related to weaknesses in self-regulation mechanisms, may also be related to TTH.

Previous research has reported that children and adolescents with TTH tend to display more emotional and shy temperament profiles and may show heightened stress reactivity [17]. The low arousal threshold observed in children diagnosed with TTH leads to quicker and more intense reactions to external or internal stimuli, which may be associated with the development or maintenance of TTH [17]. When combined with reduced self-regulation capacity, such reactivity may increase susceptibility to stress-related somatic symptoms, including headaches [13,30]. Rather than representing a direct or causal mechanism, low effortful control may play a contributory role in the maintenance or exacerbation of headache symptoms [31]. In this context, low levels of effortful control may be considered a potential psychological mechanism associated with TTH rather than a definitive mediating factor. The absence of significant temperament differences between the migraine and control groups in our study is partially consistent with some previous findings [16,18]. For example, Mazzone et al. [19] reported that children with migraine demonstrated temperament characteristics similar to healthy controls and more advantageous profiles than the TTH group in certain subdimensions. However, the literature remains mixed [32,33]. It is thought that these individuals’ coping mechanisms for stress and their responses to life’s difficulties may play a greater role in the development of migraine than their temperament [32]. More fundamentally, migraine is a disease with a distinct neurovascular nature. Therefore, it may be less closely associated with temperament, and it is likely that emotional difficulties in these children are predominantly expressed through secondary or comorbid psychiatric conditions [34]. Differences across studies may be related to variations in sample characteristics, methodological approaches, and measurement tools.

In our study, we found that children and adolescents diagnosed with migraine experienced significantly more difficulties than healthy controls in areas of emotion regulation, such as inability to sustain goal-directed behaviors (goals) and inability to develop effective coping strategies (strategies). These findings are consistent with previous research. For instance, Toknaz et al. [5] reported in their study that adolescents diagnosed with migraine experienced more emotion regulation difficulties compared to healthy controls. Difficulties in emotion regulation may adversely affect not only emotional processing but also biological resilience. Kökönyei et al. [35] have pointed out that difficulties in emotion regulation are associated with increased psychological burden in chronic pain patients and have suggested that this condition may play a role in the persistence of chronic symptoms. Given the recurrent and often chronic nature of migraine, it is plausible that emotion regulation difficulties may be associated with the course of the disorder, although the directionality of this relationship cannot be determined within a cross-sectional design.

Moreover, studies have shown that children and adolescents with migraine tend to exhibit higher levels of alexithymic traits, characterized by difficulties in identifying and describing emotions [36,37]. Emotional awareness and expression are core components of effective emotion regulation, and deficits in these capacities may contribute to the internalization of distress and its manifestation through somatic symptoms such as headaches [13]. In this context, migraine-related emotional difficulties may reflect challenges in processing and articulating affective experiences rather than a direct causal mechanism. Future longitudinal studies are needed to clarify whether emotion regulation difficulties precede migraine symptoms or emerge as a consequence of living with a chronic pain condition.

In our study, the finding that children diagnosed with TTH did not show significant differences in emotion regulation skills compared to healthy controls appears to contradict some findings in the literature; however, this discrepancy may be explained by various factors. Firstly, it has been suggested that the relationship between TTH and emotion regulation may be indirect and complex [13]. This indirect relationship may be mediated by temperament, which is a much more structural feature than emotion regulation [30]. Indeed, the fact that effortful control levels were found to be significantly lower in our study suggests that temperamental factors, which play a more fundamental role in regulating emotional responses, may be more dominant in TTH. Therefore, emotion regulation challenges in TTH may be better understood as being associated with temperament-related differences in regulatory capacity rather than representing an isolated dysfunction. Additionally, some studies conducted with adults have shown that emotion regulation disorders are only prominent in the chronic TTH subgroup; for example, Romero-Godoy et al. [38] reported that emotion regulation difficulties were only significant in individuals with long-term and intense TTH symptoms. Since our sample consisted of children and adolescents who were not diagnosed with chronic TTH, developmental stage and illness duration may partially explain the absence of significant emotion regulation differences in this group. These findings underscore the importance of considering developmental and clinical characteristics when interpreting emotion regulation profiles in pediatric headache populations.

The persistence of significantly higher MDD scores in the migraine group after controlling for age, sex, parental education level, and socioeconomic status further highlights the robust association between migraine and depressive symptoms. The relationship between migraine and depression has frequently been described as bidirectional in the literature, with suggestions that these conditions may share partially overlapping neurobiological mechanisms [39]. Particularly, dysregulations in the serotonin and dopamine systems have been reported to influence both migraine and depressive symptoms [40]. However, given the cross-sectional nature of our study, these findings should be interpreted as associative rather than causal. In contrast, the absence of significantly elevated depressive symptoms in the TTH group may suggest that TTH in pediatric populations is more closely related to stress sensitivity, temperament-based regulatory characteristics, and environmental influences, whereas depressive symptoms may represent a secondary or less prominent feature [38].

Several limitations should be considered when interpreting these findings. First, due to the cross-sectional design, causal inferences regarding the directionality between headache disorders and psychological characteristics cannot be made. Second, participants were recruited from a clinical outpatient setting, which may limit the generalizability of the findings to community-based populations and may overrepresent individuals with more pronounced symptoms. Although differences in age and socioeconomic variables were observed between groups, these variables were statistically controlled in the analyses, thereby reducing their confounding influence. Nevertheless, the wide age range of 9-18 years and the use of self-report measures may introduce developmental variability in comprehension and response patterns, particularly among younger participants. Future studies employing longitudinal designs, multi-informant assessments, and community-based samples would provide more comprehensive insight.

Despite these limitations, this study has several strengths. It simultaneously examined migraine, TTH, and healthy control groups within a pediatric population and evaluated both temperament and emotion regulation characteristics while controlling for key sociodemographic variables. To our knowledge, few studies have investigated these structural psychological dimensions together across these three groups in children and adolescents. By addressing both shared and distinct psychological profiles, the present findings contribute to a more nuanced understanding of primary headaches beyond secondary psychiatric comorbidity.

In conclusion, the results suggest that primary headache disorders in childhood and adolescence may be associated not only with depressive symptoms but also with relatively stable psychological characteristics such as temperament and emotion regulation abilities. Rather than indicating deterministic or innate causation, these findings may reflect shared vulnerability patterns or trait-like predispositions that interact with developmental and environmental factors. Longitudinal and neurobiologically informed research is needed to clarify the temporal relationships and potential mechanisms linking psychological characteristics with the onset and course of primary headaches.