Differentiating Tension-Type Headache from Migraine
Clinical Distinction
Migraine presents with unilateral, pulsating pain of moderate-to-severe intensity that worsens with routine physical activity and is accompanied by nausea and/or photophobia and phonophobia, while tension-type headache presents with bilateral, mild-to-moderate pressing or tightening pain that is not aggravated by routine activity and lacks migraine-associated symptoms. 1
Key Diagnostic Features
Migraine characteristics:
- Unilateral location (though can be bilateral) 1
- Pulsating quality 1
- Moderate-to-severe intensity 1
- Aggravated by routine physical activity 1
- Associated with nausea/vomiting 2
- Photophobia and phonophobia present 2
- May include visual aura or other sensory changes 2
Tension-type headache characteristics:
- Bilateral location 1
- Pressing or tightening (non-pulsating) quality 1
- Mild-to-moderate intensity 1
- NOT worsened by routine physical activity 1
- Lacks nausea, photophobia, and phonophobia 1
Important Diagnostic Caveats
Patients commonly have both conditions as separate disorders—not a "mixed" headache. The International Classification of Headache Disorders does not recognize a mixed migraine-tension type category; each should be diagnosed independently when both are present. 1 This is a critical pitfall: clinicians often incorrectly label overlapping symptoms as "mixed headache" when the patient actually experiences two distinct primary headache disorders. 3
Distinguishing between chronic forms can be particularly challenging, as symptom overlap increases when both conditions become chronic. 4 When diagnostic uncertainty exists between the two, it is reasonable to err on the side of migraine because misdiagnosing migraine as tension-type headache may preclude patients from receiving appropriate migraine-specific treatment. 5
Acute Treatment
For Migraine
NSAIDs are first-line treatment for all migraine attacks, including severe attacks that have previously responded to NSAIDs. 3
First-line acute therapy:
- Ibuprofen 400-800 mg at headache onset 2
- Naproxen sodium 500-825 mg 2
- Aspirin 1000 mg 3
- Combination of acetaminophen + aspirin + caffeine 3, 2
- Acetaminophen alone is ineffective for migraine 3, 2
Triptans for moderate-to-severe migraine:
- Oral triptans: sumatriptan, rizatriptan, naratriptan, zolmitriptan 3
- Subcutaneous sumatriptan for very rapid onset 3
- Intranasal sumatriptan for patients with nausea/vomiting 3
- Add a triptan to an NSAID if NSAIDs alone are inadequate 6
- Contraindicated in patients with cardiac risk factors, basilar or hemiplegic migraine, or uncontrolled hypertension 3
Intranasal dihydroergotamine (DHE) has good evidence as monotherapy for acute migraine. 3
For Tension-Type Headache
First-line acute therapy:
- Ibuprofen 400 mg at headache onset 2
- Acetaminophen 1000 mg 2
- Acetaminophen 500-650 mg is inadequate and should be avoided 2
Preventive Treatment
Indications for Preventive Therapy
Initiate preventive therapy if:
- Headaches occur ≥2 times per month with disability lasting ≥3 days per month 6
- Using acute medications more than 2 days per week 2, 6
- Contraindications to or failure of multiple acute treatments 6
For Migraine
First-line preventive options:
- Propranolol 80-240 mg/day: Start low and titrate slowly until clinical benefit or side effects limit further increases 6
- Beta-blockers (propranolol or metoprolol) particularly if no contraindications like asthma 2
- Tricyclic antidepressants 7
- Antiepileptics 7
- Botulinum toxin for chronic migraine 7
For Tension-Type Headache (Chronic: ≥15 days/month)
Amitriptyline 50-100 mg daily is the only drug with consistent evidence for reducing monthly headache days in chronic tension-type headache. 2
Amitriptyline dosing strategy:
- Initiate 10-25 mg at bedtime 1
- Titrate gradually over weeks to months to target of 30-150 mg/day 1
- Maintain therapeutic dose for 2-3 months before deeming trial unsuccessful 1
- Monitor for anticholinergic effects (dry mouth, constipation, urinary retention), especially in older adults and those with cardiac comorbidities 2
- Be aware of overdose potential and weight gain 2
For patients with both migraine and tension-type headache features, amitriptyline is the preferred preventive medication. 1
OnabotulinumtoxinA is NOT recommended for chronic tension-type headache due to lack of efficacy in pooled data from 12 randomized controlled trials. 2
Special Populations
Pregnancy
Acute treatment:
- Acetaminophen 1000 mg is first-line for both migraine and tension-type headache 1
- NSAIDs (ibuprofen 400 mg) safe in first and second trimesters but must be avoided in third trimester due to risk of premature ductus arteriosus closure 1
- Triptans generally contraindicated unless benefit clearly outweighs risk 1
- Ergot alkaloids contraindicated throughout pregnancy 1
Preventive treatment:
- Amitriptyline is preferred for pregnant patients with both migraine and tension-type headache features 1
- Valproate should be avoided due to teratogenic potential 1
Adolescent Females
- Assess relationship between headaches and menstrual cycle, as hormonal fluctuations commonly trigger migraine 2
- Short-term prophylaxis with NSAIDs starting 2-3 days before expected menses can be considered for menstrual migraine 2
Red Flags Requiring Immediate Neuroimaging
Obtain MRI or CT immediately if:
- Sudden "thunderclap" onset 6
- Headache worsens with Valsalva maneuver or awakens patient from sleep 2, 6
- Progressive worsening pattern 2
- Abnormal neurologic examination 2, 6
- Fever or unexplained systemic symptoms 6
- New onset in patient over age 50 6
- Rapidly increasing frequency or severity 6
Critical Pitfall: Medication Overuse Headache
Before escalating therapy for treatment-resistant headache, assess for medication overuse headache: regular use of acute medications on ≥10 days/month for triptans or ≥10 days/month for any combination of acute medications for ≥3 months. 6 This is a common cause of treatment failure and must be addressed before adding preventive therapy.