What is the difference in treatment approach between migraines and tension headaches?

Differences in Treatment Approach Between Migraines and Tension Headaches

The treatment approach for migraines should focus on migraine-specific medications like triptans and gepants for acute attacks, while tension headaches primarily respond to simple analgesics and NSAIDs, with different preventive strategies for each condition based on their distinct pathophysiology. 1

Diagnostic Differences

Migraine Characteristics

• Pain pattern: Unilateral, throbbing/pulsating, moderate to severe intensity
• Associated symptoms: Nausea/vomiting, photophobia, phonophobia
• Effect on activity: Worsened by routine physical activity
• Duration: 4-72 hours untreated

Tension-Type Headache Characteristics

• Pain pattern: Bilateral, pressing/tightening (non-pulsatile), mild to moderate intensity
• Associated symptoms: Minimal or absent nausea, may have photophobia OR phonophobia (but not both)
• Effect on activity: Not aggravated by routine physical activity
• Duration: 30 minutes to 7 days

Acute Treatment Approaches

For Migraine Headaches

1. First-line for mild-moderate attacks:

   • NSAIDs (ibuprofen, naproxen)
   • Acetaminophen
   • Aspirin + caffeine combinations

2. First-line for moderate-severe attacks:

   • Triptans (sumatriptan, rizatriptan, etc.)
   • Gepants (rimegepant, ubrogepant) - especially for patients with cardiovascular contraindications to triptans 2
   • Ditans (lasmiditan) - for patients with cardiovascular risk factors 2

3. Second-line options:

   • Antiemetics (metoclopramide, prochlorperazine)
   • Ergot alkaloids (dihydroergotamine)

For Tension-Type Headaches

1. First-line:

   • NSAIDs (ibuprofen, naproxen)
   • Acetaminophen

2. Second-line:

   • Combination analgesics with caffeine
   • Muscle relaxants (for episodic use only)

Preventive Treatment Approaches

For Migraine Prevention

1. First-line pharmacologic options:

   • Beta-blockers (propranolol 80-240 mg/day, timolol 20-30 mg/day)
   • Topiramate (25-100 mg/day)
   • Divalproex sodium/sodium valproate (500-1500 mg/day)
   • Amitriptyline (30-150 mg/day) 3

2. Second-line pharmacologic options:

   • Angiotensin receptor blockers (candesartan 8-32 mg/day)
   • CGRP monoclonal antibodies
   • Venlafaxine (75-150 mg/day) 3
   • OnabotulinumtoxinA (for chronic migraine)

For Tension-Type Headache Prevention

1. First-line pharmacologic options:

   • Tricyclic antidepressants (amitriptyline is best studied)
   • Muscle relaxants (for short-term use)

2. Second-line pharmacologic options:

   • SSRIs/SNRIs
   • Mirtazapine

Non-Pharmacologic Approaches

For Both Headache Types

1. Physical interventions:

   • Aerobic exercise or progressive strength training 1
   • Physical therapy (especially for tension headaches with muscle involvement)

2. Behavioral interventions (evidence insufficient but commonly used):

   • Biofeedback
   • Cognitive behavioral therapy
   • Relaxation techniques
   • Stress management 1, 3

3. Lifestyle modifications:

   • Regular sleep schedule
   • Regular meals
   • Adequate hydration
   • Stress management
   • Trigger identification and avoidance 3

Treatment Pitfalls and Caveats

1. Medication overuse headache risk:

   • Limit acute medications to ≤2 days/week for simple analgesics
   • Limit triptans, combination analgesics to ≤10 days/month
   • This is particularly important in migraine patients who are more prone to medication overuse headache 1

2. Special populations:

   • Pregnancy: Avoid valproate and topiramate due to teratogenicity
   • Cardiovascular disease: Avoid triptans and ergots; consider gepants or ditans instead
   • Women with migraine with aura: Avoid estrogen-containing contraceptives due to increased stroke risk 3

3. Treatment evaluation:

   • Evaluate response to preventive treatment after 6-8 weeks
   • Target goal: 50% reduction in headache frequency
   • Consider specialist referral if inadequate response after 2-3 preventive medication trials 3

By understanding these key differences in treatment approach, clinicians can more effectively manage these common but distinct headache disorders, improving patient outcomes and quality of life.