How can I distinguish migraine from tension-type headache?

How to Distinguish Migraine from Tension-Type Headache

To distinguish migraine from tension-type headache (TTH), focus on these key differentiating features: migraine typically presents with moderate-to-severe unilateral, pulsating pain aggravated by routine physical activity, accompanied by nausea/vomiting and/or both photophobia and phonophobia, whereas TTH presents with bilateral, pressing/tightening (non-pulsating) pain of mild-to-moderate intensity without these associated features 1.

Diagnostic Criteria-Based Approach

Migraine Without Aura - Key Features 1:

Requires at least 5 attacks with:

Pain characteristics (need ≥2 of 4):

• Unilateral location (though ~40% report bilateral pain)
• Pulsating quality
• Moderate or severe intensity
• Aggravation by or causing avoidance of routine physical activity (walking, climbing stairs)

Associated symptoms (need ≥1):

• Nausea and/or vomiting
• Both photophobia AND phonophobia

Duration: 4-72 hours when untreated

Tension-Type Headache - Key Features 2:

Pain characteristics:

• Bilateral location
• Pressing or tightening (non-pulsating) quality
• Mild-to-moderate intensity
• NOT aggravated by routine physical activity

Associated symptoms:

• May have photophobia OR phonophobia (not both)
• No nausea or vomiting (though mild nausea can occur in chronic TTH)

Clinical Discriminators in Practice

Features That Strongly Suggest Migraine Over TTH 3, 4:

Symptom profile:

• Photophobia AND phonophobia together (not just one)
• Nausea/vomiting (68% vs 6% in TTH for nausea; 38% vs 0% for vomiting)
• Osmophobia (sensitivity to smells)
• Cranial autonomic symptoms (conjunctival injection, lacrimation, periorbital swelling, nasal symptoms)

Pain behavior:

• Aggravation by head bending or physical exercise
• Progressive worsening over time in severity, frequency, and duration
• Post-headache lethargy
• Response to analgesics (more likely in migraine)

Triggers that favor migraine:

• Weather changes
• Specific smells
• Smoke exposure
• Not eating on time
• Menstruation

Features That Suggest TTH 3, 4:

• Stress as primary trigger (more specific for TTH)
• Muscle parafunction (46% vs 20% in migraine)
• Pericranial tenderness on examination
• Absence of the migraine-specific features listed above

Critical Diagnostic Pitfalls

Common Overlaps That Complicate Diagnosis 5, 6, 7:

Important caveats:

• Both conditions can be triggered by stress and psychological factors
• Both may have moderate pain severity
• Chronic TTH can develop mild nausea
• Many migraine attacks include neck pain (tension-like symptoms)
• TTH can have photophobia OR phonophobia (but not both simultaneously)
• Psychophysical testing cannot reliably distinguish chronic migraine from chronic TTH 7

When in doubt, favor migraine diagnosis 8. Migraine is significantly underdiagnosed, and misdiagnosing migraine as TTH has more serious consequences because it prevents patients from receiving migraine-specific treatments (triptans, CGRP antagonists) that could substantially improve their quality of life.

Practical Diagnostic Algorithm

Step 1: Assess pain characteristics

• If unilateral + pulsating + moderate-severe + worsened by activity → suspect migraine
• If bilateral + pressing/tightening + mild-moderate + not worsened by activity → suspect TTH

Step 2: Evaluate associated symptoms

• If nausea/vomiting present → migraine
• If both photophobia AND phonophobia present → migraine
• If only one or neither present → consider TTH

Step 3: Check for migraine-specific features

• Aura symptoms (visual, sensory, speech disturbances spreading gradually over ≥5 minutes) → migraine with aura 1
• Cranial autonomic symptoms → migraine
• Osmophobia → migraine

Step 4: Consider frequency pattern

• If ≥15 headache days/month for >3 months with migraine features on ≥8 days/month → chronic migraine 1

Step 5: Family history

• Positive family history of migraine strengthens migraine diagnosis 1

Additional Considerations

Red flags requiring further investigation (not TTH or migraine) 1:

• Thunderclap headache
• Progressive headache
• New onset after age 50
• Focal neurological symptoms
• Fever with neck stiffness
• Altered consciousness

Both conditions can coexist 1. A patient may have both migraine and TTH, requiring diagnosis of both conditions when criteria are met.

The specificity of diagnostic criteria for distinguishing migraine from TTH is 94% with a positive predictive value of 99% 9, making the formal ICHD-3 criteria highly reliable when properly applied. The most specific symptoms for migraine are severity, photophobia, phonophobia, and vomiting 9.