What is the difference between tension headaches and migraines in terms of diagnosis and treatment?

Distinguishing Tension-Type Headache from Migraine

Tension-type headache presents with bilateral, pressing or tightening pain of mild-to-moderate intensity without nausea or significant photophobia/phonophobia, while migraine features unilateral, pulsating, moderate-to-severe pain with nausea/vomiting and/or photophobia and phonophobia. 1

Key Diagnostic Features

Tension-Type Headache Characteristics

• Pain quality: Bilateral pressing or tightening sensation, described as band-like distribution from forehead to occiput 1, 2
• Pain intensity: Mild to moderate severity 1, 3
• Pain location: Typically bilateral, though can occasionally be unilateral 4
• Aggravating factors: NOT worsened by routine physical activity 1, 3
• Associated symptoms: Lacks the characteristic migraine features—no nausea, vomiting, or significant photophobia/phonophobia 1, 5
• Duration: Variable, but typically constant pressure-like quality 2

Migraine Characteristics

• Pain quality: Pulsating or throbbing character 1, 4
• Pain intensity: Moderate to severe, often disabling 1
• Pain location: Frequently unilateral, though can be bilateral 1, 4
• Duration: 4-72 hours when untreated 1, 5
• Aggravating factors: Worsened by routine physical activity 1, 3
• Associated symptoms: At least two of the following: nausea, vomiting, photophobia, phonophobia 1
• Behavioral response: Patients prefer to lie still in a dark, quiet room 5

Diagnostic Approach Algorithm

Step 1: Characterize the Headache Pattern

• Document duration: If 4-72 hours, favor migraine; if variable or constant, consider tension-type 1, 5
• Assess pain quality: Pulsating suggests migraine; pressing/tightening suggests tension-type 1, 4
• Determine laterality: Unilateral pain increases likelihood of migraine, though bilateral doesn't exclude it 1, 4

Step 2: Identify Associated Symptoms

• Presence of nausea/vomiting strongly suggests migraine rather than tension-type headache 1
• Photophobia AND phonophobia together indicate migraine 1
• Absence of these features supports tension-type headache 1, 2

Step 3: Assess Activity Impact

• If routine physical activity worsens headache, diagnose migraine 1, 3
• If physical activity has no effect or patient continues activities, favor tension-type 1, 3

Step 4: Use Screening Tools When Uncertain

• Apply ID-Migraine questionnaire (sensitivity 0.81, specificity 0.75): asks about photophobia, nausea, and disability from headache 1
• When in doubt between diagnoses, err toward migraine as it is frequently underdiagnosed and requires specific treatment 6, 7

Critical Diagnostic Pitfalls

Common Misdiagnosis Scenarios

• Many migraine attacks include neck pain and tension-like features, leading to misdiagnosis as tension-type headache 7
• Some tension-type headaches have mild photophobia or phonophobia, creating diagnostic confusion 7
• Rigid adherence to requiring ALL migraine criteria may result in undertreating disabling headaches 7

Red Flags Requiring Further Investigation

• New-onset headache in patients over 50 years requires exclusion of giant cell arteritis 4, 3
• Focal neurological deficits, atypical pattern, or progressive worsening mandate neuroimaging 4, 3
• Thunderclap onset, impaired memory, or unexplained fever suggest secondary causes 1

Treatment Distinctions

Acute Treatment for Tension-Type Headache

• Over-the-counter NSAIDs are first-line therapy 8, 2
• Avoid using analgesics more than twice weekly to prevent medication-overuse headache 2
• Sedating antihistamines or antiemetics can potentiate analgesic effects 2

Acute Treatment for Migraine

• Triptans should be offered for moderate-to-severe attacks or when simple analgesics fail 1, 8
• Combination therapy with NSAIDs plus triptans is more effective than either alone 8
• Antiemetics address nausea and may have independent antimigraine effects 1

Preventive Treatment Differences

• For tension-type: Amitriptyline is the most evidence-based prophylactic agent 2
• For migraine: Multiple options exist including β-blockers, topiramate, CGRP monoclonal antibodies, and botulinum toxin for chronic migraine 4, 8
• Preventive therapy is warranted when headaches occur ≥15 days/month (chronic migraine) or cause significant disability 1

When Diagnosis Remains Uncertain

Use of Headache Diaries

• Daily diary entries documenting frequency, intensity, duration, associated symptoms, and medication use clarify diagnosis over 4-8 weeks 1
• Electronic diaries facilitate detailed tracking without compromising compliance 1

Probable Migraine Category

• When attacks are migraine-like but missing one diagnostic criterion, diagnose as "probable migraine" and treat as migraine 1
• Re-evaluate diagnosis during early follow-up visits using diary data 1

Family History Considerations

• Positive family history of migraine strengthens suspicion, as migraine has strong genetic component 1
• Onset at or around puberty further supports migraine diagnosis 1