Differentiating Tension Headaches from Migraine Headaches
Tension-type headaches present with bilateral, pressing or tightening pain of mild-to-moderate intensity that is not aggravated by routine physical activity and lacks the accompanying symptoms characteristic of migraine, whereas migraines typically feature unilateral, throbbing pain of moderate-to-severe intensity that worsens with activity and is accompanied by nausea/vomiting and/or photophobia and phonophobia. 1, 2
Key Distinguishing Features
Pain Characteristics
Location and Quality:
- Tension-type headache: Bilateral pain affecting both sides of the head with a pressing, tightening, or non-pulsatile character 2
- Migraine: Often unilateral (one-sided) with a throbbing or pulsating quality 2
Intensity:
Effect of Physical Activity:
- Tension-type headache: Not aggravated by routine physical activity 1, 2
- Migraine: Worsens with routine physical activity 2
Associated Symptoms
Tension-type headache typically lacks:
- Nausea and vomiting (though anorexia may be present) 2
- Both photophobia AND phonophobia together (may have one but not both) 2
Migraine characteristically includes:
- Nausea and/or vomiting 2
- Both photophobia (light sensitivity) AND phonophobia (sound sensitivity) 2
- Patients prefer to lie still in a dark, quiet room 3
Duration
Clinical Approach to Diagnosis
Use Validated Screening Tools
For suspected migraine, employ:
- The three-item ID-Migraine questionnaire (sensitivity 0.81, specificity 0.75, positive predictive value 0.93) 1
- The five-item Migraine Screen Questionnaire (sensitivity 0.93, specificity 0.81, positive predictive value 0.83) 1
Apply ICHD-3 Diagnostic Criteria
- Take a careful medical history using International Classification of Headache Disorders criteria 1
- Consider using headache diaries to document patterns and associated symptoms 1
Important Clinical Pitfalls
Overlapping Features
Be aware that rigid adherence to diagnostic criteria can lead to misdiagnosis:
- Many migraine attacks include tension headache-like symptoms such as neck pain 4
- Some tension-type headaches may have migraine-like features including photophobia, phonophobia, or aggravation by activity 4
- When diagnostic uncertainty exists between primary headaches, it is reasonable to err on the side of migraine diagnosis, as migraine is frequently underdiagnosed and undertreated 5
Red Flags Requiring Further Investigation
Always exclude secondary headache disorders when these features are present:
- Thunderclap headache (sudden onset of worst headache of life) 1, 6
- Focal neurological symptoms or signs 1, 6
- Unexplained fever 1, 6
- Impaired memory or personality changes 1, 6
- Head trauma 1, 6
- Papilledema or neck stiffness 6
- Headache that is worse with exercise 6
Neuroimaging Indications
Routine neuroimaging is NOT indicated for typical tension-type headaches or migraines without red flags:
- Neuroimaging should only be used when a secondary headache disorder is suspected based on red flags in history or physical examination 1, 2
- MRI is preferred over CT when neuroimaging is needed, as it offers higher resolution without ionizing radiation exposure 1
- Unnecessary neuroimaging can reveal clinically insignificant abnormalities (white matter lesions, arachnoid cysts, meningiomas) that alarm patients and lead to further unnecessary testing 1
Additional Differential: Cluster Headache
If considering cluster headache in the differential:
- Strictly unilateral, severe pain lasting only 15-180 minutes 1, 3
- Accompanied by ipsilateral autonomic symptoms (conjunctival injection, lacrimation, nasal congestion, ptosis) 1, 3
- Frequency of 1-8 attacks daily during cluster periods 3
- Much less prevalent (~0.1% of population) than tension-type headache or migraine 1