How can I distinguish tension‑type headache from migraine based on clinical features and what are the first‑line acute and preventive treatment options for each?

Distinguishing Tension-Type Headache from Migraine

Tension-type headache presents as bilateral, pressing/tightening pain of mild-to-moderate intensity that is not aggravated by routine activity and lacks both nausea/vomiting and the combination of photophobia plus phonophobia, whereas migraine is characterized by unilateral, pulsating, moderate-to-severe pain aggravated by activity with nausea/vomiting or both photophobia and phonophobia. 1, 2

Clinical Features for Differentiation

Tension-Type Headache Characteristics

• Pain quality and location: Bilateral, pressing or tightening (non-pulsatile) character with mild-to-moderate severity 1, 2
• Activity relationship: Not worsened by routine physical activity such as walking or climbing stairs 1
• Associated symptoms: May have anorexia but typically lacks nausea/vomiting; does not have both photophobia and phonophobia together 1, 2
• Duration: Highly variable, ranging from 30 minutes to 7 days per episode 2
• Behavioral response: Patients predominantly report scalp massage as a relief measure 3

Migraine Characteristics

• Pain quality and location: Unilateral (though can be bilateral), pulsating or throbbing quality with moderate-to-severe intensity 2, 4
• Activity relationship: Aggravated by routine physical activity 2
• Associated symptoms: Nausea/vomiting AND/OR both photophobia and phonophobia present together 2, 4
• Duration: 4-72 hours in adults (2-72 hours in children under 18 years) 2
• Diagnostic threshold: Requires at least 5 lifetime attacks meeting these criteria 2
• Behavioral response: Patients perform significantly more relief maneuvers (mean 6.2 vs 3 for tension-type), including pressing the painful site, applying cold stimuli, attempting to sleep, isolating themselves, and becoming immobile 3

Key Discriminating Features

• The presence of photophobia together with nausea strongly supports migraine and helps differentiate it from tension-type headache 2
• Migraine patients typically seek isolation and immobility during attacks, while tension-type headache patients continue activities 3
• Approximately one-third of migraine patients experience aura (visual, sensory, or speech disturbances lasting 5-60 minutes) preceding or accompanying headache 4, 2

Common Diagnostic Pitfalls

• Overlap exists: Many migraine attacks include tension-like symptoms such as neck pain, and some tension-type headaches may have mild photophobia or phonophobia (but not both together) 5
• Misdiagnosis consequences: Rigid adherence to diagnostic criteria may result in migraine being misdiagnosed as tension-type headache, preventing patients from receiving appropriate migraine-specific treatment 5, 6
• When in doubt, favor migraine: It is reasonable to err on the side of migraine diagnosis when choosing between primary headaches, as migraine is significantly underdiagnosed and undertreated 6
• Chronic forms complicate diagnosis: Chronic tension-type headache (≥15 days/month) can have disability levels comparable to migraine 2
• Medication overuse: Headache on ≥15 days/month with regular overuse of non-opioid analgesics ≥15 days/month or other acute medications ≥10 days/month for ≥3 months indicates medication-overuse headache, which can mimic either condition 2

First-Line Acute Treatment

Tension-Type Headache

• NSAIDs: Ibuprofen 400 mg is first-line acute treatment 4
• Acetaminophen: 1000 mg is an alternative first-line option 4
• Avoid opioids and barbiturates: These carry dependency risk and can lead to medication-overuse headache 4

Migraine

• Mild-to-moderate attacks: NSAIDs or acetaminophen 2
• Moderate-to-severe attacks or NSAID failure: Triptans are first-line 4
• Newer options: CGRP receptor antagonists (gepants) such as ubrogepant or rimegepant are recommended as acute treatment options 4
• Combination therapy: Aspirin-acetaminophen-caffeine combination is effective 4
• Antiemetics: Add for nausea/vomiting 2
• Avoid opioids: Opioids are not recommended due to dependency risk, rebound headaches, and loss of efficacy 4

Preventive Treatment

Tension-Type Headache (Chronic Form)

• Amitriptyline: First-line preventive agent for chronic tension-type headache (≥15 days/month) 4, 2, 7
• Physical therapy: Combination of thermal methods, trigger point massage, and mobilization techniques delivered by a physical therapist 4
• Aerobic exercise: 2-3 times per week for 30-60 minutes 4

Migraine Prevention

• First-line options:

  • Beta-blockers: Propranolol, metoprolol, atenolol, or bisoprolol (particularly useful with comorbid hypertension) 4, 8
  • Angiotensin-receptor blockers: Candesartan 4
  • ACE inhibitors: Lisinopril 4
  • Antiepileptics: Topiramate 50-100 mg daily (especially beneficial in obese patients) 4, 8
  • Valproate (contraindicated in women of childbearing potential) 4

• CGRP monoclonal antibodies: Eptinezumab, erenumab, fremanezumab, galcanezumab are options for migraine prevention 4

• Newer oral options: Atogepant (oral CGRP antagonist) 4

• Botulinum toxin: OnabotulinumtoxinA 155-195 units every 12 weeks is recommended for chronic migraine (≥15 headache days/month with ≥8 meeting migraine criteria) but NOT for episodic migraine or tension-type headache 4, 8

• Gabapentin is NOT recommended for episodic migraine prevention 4

Non-Pharmacological Approaches (Both Conditions)

• Physical therapy: Thermal methods, trigger point massage, mobilization and manipulation techniques are beneficial for both migraine and tension-type headache 4
• Aerobic exercise: 2-3 times per week for 30-60 minutes 4
• Progressive strength training: Upper-body exercises, supervised, typically 3 times per week for 30 minutes 4

Treatment Assessment

• Oral preventives: Assess efficacy after 2-3 months at therapeutic dose 8, 2
• CGRP antibodies: Assess after 3-6 months 8
• Botulinum toxin: Assess after 6-9 months 8
• Consider pausing treatment after 6-12 months of successful control to determine if preventive therapy can be stopped 8, 2
• Headache diary: Document frequency, duration, character, triggers, accompanying symptoms, and medication use to facilitate monitoring 2