How do you differentiate and manage a patient with symptoms suggestive of either combination headache or migraine?

Differentiating and Managing Combination Headache versus Migraine

The term "combination headache" refers to patients experiencing both migraine and tension-type headache, and differentiation requires systematic application of ICHD-3 criteria through detailed history-taking and headache diaries, with management involving treatment of both headache types simultaneously when they coexist. 1, 2

Understanding Combination Headache

Combination headache is not a distinct diagnostic entity but rather describes patients who experience both migraine and tension-type headache. 3 This clinical scenario is common in practice and requires recognition of both headache patterns rather than forcing a single diagnosis. The key is identifying whether the patient has two separate headache types or a single primary headache disorder. 2

Systematic Diagnostic Approach

Essential History Elements

The medical history is the cornerstone of diagnosis and must systematically capture: 1

• Age at onset: Migraine typically begins at or around puberty 1, 2
• Duration of episodes: Migraine lasts 4-72 hours when untreated, while tension-type headache has variable duration 2, 4
• Frequency: Document whether headaches occur ≥15 days/month (suggesting chronic migraine or medication-overuse headache) 2
• Pain location: Unilateral location suggests migraine; bilateral pressing/tightening suggests tension-type headache 2, 4
• Pain quality: Pulsating quality indicates migraine; pressing/tightening quality indicates tension-type headache 2, 5
• Pain severity: Moderate-to-severe intensity suggests migraine; mild-to-moderate suggests tension-type headache 2
• Aggravating factors: Routine physical activity worsens migraine but not tension-type headache 2, 5

Critical Accompanying Symptoms

For migraine diagnosis, you must document at least one of the following: nausea/vomiting OR both photophobia AND phonophobia. 2, 5 Tension-type headache lacks these migraine-associated features. 2

Aura symptoms (visual, sensory, or speech disturbances lasting <60 minutes) confirm migraine with aura if present. 2

Medication History

Document all acute medication use carefully, as ≥15 days/month of non-opioid analgesics or ≥10 days/month of other acute medications for ≥3 months indicates medication-overuse headache, which fundamentally changes management. 2

Applying ICHD-3 Diagnostic Criteria

Confirming Migraine Without Aura

Migraine without aura requires ALL of the following: 2, 5

• At least 5 lifetime attacks lasting 4-72 hours (when untreated)
• At least 2 pain characteristics: unilateral location, pulsating quality, moderate-to-severe intensity, OR aggravation by routine physical activity
• At least 1 accompanying symptom: nausea/vomiting OR photophobia AND phonophobia

Confirming Tension-Type Headache

Tension-type headache is characterized by: 2, 5

• Bilateral location
• Pressing or tightening (non-pulsating) quality
• Mild-to-moderate intensity
• NOT aggravated by routine physical activity
• Absence of nausea/vomiting
• May have photophobia OR phonophobia (but not both)

Identifying Combination Headache

If the patient's headache diary documents attacks meeting migraine criteria on some occasions and tension-type criteria on others, this represents combination headache requiring dual treatment strategies. 3

Essential Diagnostic Tools

Headache Diary

Implement a headache diary immediately—this is the single most important diagnostic tool for differentiating headache types and reducing recall bias. 1, 2 The diary must document for each headache episode: 1

• Date and time of onset
• Duration
• Pain location and quality
• Severity (0-10 scale)
• Accompanying symptoms (nausea, photophobia, phonophobia)
• Medication use and response
• Triggers or precipitating factors

Diary entries that consistently fail to meet ICHD-3 criteria for migraine over multiple attacks effectively rule out migraine. 2

Screening Questionnaires

Use the ID-Migraine questionnaire (3 questions: nausea, photophobia, disability) with sensitivity 0.81 and positive predictive value 0.93 to screen for migraine. 1, 2 However, screening tools must be confirmed with detailed history and diary review. 1

Red Flags Requiring Urgent Evaluation

Before diagnosing any primary headache disorder, systematically exclude secondary causes using red flag criteria: 2, 5, 6

• Thunderclap headache ("worst headache of life")
• New-onset headache after age 50
• Progressive worsening over weeks to months
• Headache worsening with Valsalva, cough, or exertion
• Focal neurological symptoms or signs
• Unexplained fever with neck stiffness
• Recent head or neck trauma
• Headache awakening patient from sleep
• Atypical aura (focal symptoms, duration >60 minutes)

If any red flag is present, obtain MRI brain with and without contrast (preferred modality) or non-contrast CT head if presenting <6 hours from acute severe headache onset. 2

Management Strategy for Combination Headache

Acute Treatment

For migraine attacks in combination headache patients: 1, 7

• NSAIDs or acetaminophen first-line for mild-to-moderate attacks 2
• Triptans for moderate-to-severe attacks or when NSAIDs fail (rizatriptan 10 mg achieves 33% pain-free rate at 2 hours) 7
• Antiemetics for nausea/vomiting 2

For tension-type headache episodes: 8

• NSAIDs (ibuprofen, naproxen, diclofenac) or aspirin
• Avoid frequent analgesic use (limit to <15 days/month for non-opioids, <10 days/month for triptans) 2

Prophylactic Treatment for Combination Headache

When patients have both migraine and tension-type headache with sufficient frequency to warrant prevention, the rational approach is combining a beta-blocker (for migraine prophylaxis) with a tricyclic antidepressant (for tension-type headache). 3 This combination strategy addresses both headache types simultaneously:

• Amitriptyline 25-75 mg at bedtime PLUS
• Propranolol 80-240 mg daily or metoprolol 100-200 mg daily

In the only available study of this combination approach, median migraine frequency decreased from 4 to 2 attacks per 3 months, and tension headache days decreased from 21 to 6 days per month. 3

Critical Pitfall: Medication-Overuse Headache

If the patient uses acute medications ≥10-15 days/month, you must address medication-overuse headache FIRST before implementing prophylactic therapy, as preventive medications will not work effectively until medication overuse is resolved. 2 This requires:

• Complete withdrawal of overused medications
• Bridge therapy with corticosteroids or alternative acute treatments
• Patient education about rebound headache
• Close follow-up during withdrawal period

When to Refer

Refer urgently to neurology (within 48 hours) if: 2

• Suspected spontaneous intracranial hypotension (orthostatic headache)
• Patient unable to self-care but has help available

Emergency admission if: 2, 5

• Any red flag present
• Patient unable to self-care without help

Routine neurology referral (2-4 weeks) if: 2

• Diagnosis remains uncertain despite diary review
• First-line treatments fail
• Combination headache with inadequate response to dual prophylaxis

Key Clinical Pearls

The presence of family history of migraine strengthens migraine diagnosis, as migraine has strong genetic predisposition. 2

Physical examination in primary headache disorders is characteristically normal—any abnormal neurological finding warrants neuroimaging. 2, 6

Chronic migraine (≥15 headache days/month for >3 months with ≥8 days meeting migraine criteria) represents a distinct entity requiring different management than episodic migraine. 2