Mixed Migraine-Tension Type Headache: Terminology and Treatment in Pregnancy
Terminology
The term "mixed migraine-tension type headache" is outdated and should be avoided. Modern headache classification recognizes migraine and tension-type headache (TTH) as distinct entities, not a continuum 1. The International Classification of Headache Disorders (ICHD) does not include a "mixed" or "combination" headache category 2.
Key Diagnostic Distinctions:
Migraine presents with unilateral, pulsating pain of moderate-to-severe intensity, aggravated by physical activity, and accompanied by nausea and/or photophobia plus phonophobia 1
Tension-type headache involves bilateral, mild-to-moderate pain with pressing/tightening quality, not aggravated by routine physical activity, and lacks migraine-associated symptoms 1
Patients can have BOTH disorders separately - it is common for migraine patients to also experience episodic tension-type headaches, but these should be diagnosed as two distinct conditions, not as a "mixed" entity 1, 2
When Features Overlap:
If a patient presents with overlapping features, diagnose based on the predominant symptom pattern 3, 4:
- Severe intensity + nausea strongly suggests migraine 3
- Pulsating quality + migrainous location + aggravation by physical activity indicates migraine 3
- Bilateral location + mild intensity + no aggravation by physical activity + pressing-tightening quality indicates TTH 3
Treatment During Pregnancy
Acute Treatment Options:
Acetaminophen (paracetamol) 1000 mg is the first-line acute treatment for both migraine and tension-type headache in pregnancy 1. This is the safest option with the most reassuring safety data.
For moderate-to-severe migraine not responding to acetaminophen:
NSAIDs (ibuprofen 400 mg) can be used in the first and second trimesters only - they must be avoided in the third trimester due to risk of premature closure of the ductus arteriosus 1
Triptans are generally avoided in pregnancy unless the benefit clearly outweighs the risk, as they are not FDA-approved for use in pregnancy 1
Preventive Treatment (if needed):
Amitriptyline is the preferred preventive agent when a pregnant patient has both migraine and tension-type features 5. The American Academy of Neurology specifically notes that amitriptyline is superior to propranolol when patients present with both migraine and tension-type features 5.
Dosing strategy for amitriptyline:
- Start with 10-25 mg at bedtime 5
- Gradually increase over weeks to months toward target dose of 30-150 mg/day 5
- Allow 2-3 months at therapeutic dose before declaring treatment failure 5
Critical Pregnancy Considerations:
- Avoid NSAIDs entirely in the third trimester 1
- Avoid ergot alkaloids completely in pregnancy due to uterotonic effects 1
- Avoid valproate due to teratogenicity 1
- Avoid newer agents (gepants, CGRP monoclonal antibodies, ditans) as safety data in pregnancy are lacking 1
Non-Pharmacologic Approaches:
Physical therapy and aerobic exercise can be used safely in pregnancy for management of both TTH and migraine 1. These should be emphasized as first-line approaches when feasible, given the limited pharmacologic options during pregnancy.