The consulted works concur in tracing this surname to the medieval nickname Malatesta, a compound of mala ("bad, wicked") and testa ("head"), originally applied to a stubborn, malicious, or treacherous person. E. De Felice and A. Bongioanni note that as early as 1186 a Malatesta del Montefeltro is documented as the head of the celebrated lineage of lords of Romagna and the Marche, and that the nickname passed first into a given name before becoming a surname. Both scholars also indicate that the surnames Testi and Testoni derive from this same base.

E. Rossoni adds a complementary detail: toward the end of the 13th century, Malatesta I was lord of Rimini, founding a dynasty. According to a well-attested theory that Rossoni records, the family descended from a certain Rodolfo of the 10th century, nicknamed Malatesta for his obstinacy and for the courage with which he faced both the papal and the imperial faction.

Regarding geographical distribution, De Felice and Bongioanni describe the surname as extending from northern to southern Italy, with particularly high frequency in Liguria. Rossoni notes an uneven presence throughout the country.