# Pressure Pain Threshold Cut-Off Points at Trigeminal and Extra-Trigeminal Nervous and Musculoskeletal Structures to Discriminate Patients with Migraine from Episodic Tension-Type Headache: A Diagnostic Accuracy Study

## TL;DR

This study finds that pressure pain thresholds at specific body sites, especially the temporalis muscles, can help distinguish migraine patients from those with tension-type headaches, though the results are not strong enough for standalone diagnosis.

## Contribution

The study identifies site-specific pressure pain threshold cut-off values for differentiating migraine from tension-type headache using ROC analysis.

## Key findings

- Migraine patients had lower pressure pain thresholds than TTH patients, especially at the temporalis muscles.
- Temporalis muscles showed the strongest discriminatory performance with AUCs of 0.733 (left) and 0.707 (right).
- Overall, PPTs provide modest discriminatory utility and should be used as an adjunct to clinical evaluation.

## Abstract

Background/Objectives: Pressure pain thresholds (PPTs) are commonly used to quantify mechanical hyperalgesia in migraine and tension-type headache (TTH), but the discriminatory performance of PPTs across neural and muscular sites remains unclear. This study compared nerve- and muscle-related PPTs between migraine and frequent episodic TTH and explored site-specific ROC-derived cut-off values as complementary classification markers. Methods: In this cross-sectional case-group discrimination study, participants with migraine (n = 33) and frequent episodic TTH (n = 31) underwent bilateral PPT assessment (electronic algometry) over the temporalis and tibialis anterior muscles, C5/C6 zygapophyseal joints, peripheral nerves (greater occipital, median, ulnar, radial, posterior tibial, common peroneal), and the second metacarpal region. Results: PPTs were generally lower in the migraine group than in the TTH group. After adjustment for sex and age, the most consistent between-group differences remained at the temporalis muscles bilaterally (left: adjusted mean difference 0.49 kg/cm2, 95% CI 0.10 to 0.89, p = 0.015; right: 0.53 kg/cm2, 95% CI 0.13 to 0.93, p = 0.011) and at the left tibialis anterior muscle (0.90 kg/cm2, 95% CI 0.03 to 1.78, p = 0.044). In the main ROC analysis, the temporalis muscles showed the strongest discriminatory performance (left AUC = 0.733; right AUC = 0.707), whereas tibialis anterior and left posterior tibial nerve sites showed modest, below-threshold discrimination (AUCs < 0.70 despite statistical significance in some cases). Women-only ROC analyses showed a broadly similar pattern, with slightly improved metrics at some sites, particularly the temporalis muscles. Across most sites, likelihood ratios indicated only small-to-moderate shifts in post-test probability. Conclusions: Participants with migraine showed lower PPTs than those with frequent episodic TTH across most assessed sites, with the clearest differences at the temporalis muscles. ROC and PR analyses suggest that PPTs (especially at temporalis sites) may provide complementary, hypothesis-generating discriminatory information, but their overall stand-alone discriminative utility is modest. PPT assessment should therefore be interpreted as an adjunct to clinical evaluation rather than a replacement diagnostic test.