Migraine vs Tension headache
How to tell Migraine and Tension headache apart when a board question makes them look alike.
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Nausea or photophobia accompanying headache is the quickest discriminator favoring migraine over tension headache.
Side by side
Recurrent unilateral pulsatile headache with nausea and photophobia, often worsened by activity, supports migraine.
Bilateral pressing band-like pain without nausea or focal neurologic findings supports tension headache.
Trigeminovascular activation and neuropeptide release drive migraine pain and sensory hypersensitivity.
Pericranial myofascial nociception and central pain modulation changes underlie tension headache.
Migraine is a clinical diagnosis when exam is normal and no red flags are present; neuroimaging is reserved for thunderclap onset, focal deficits, papilledema, fever, or new onset after age 50.
Tension headache has normal neurologic exam and no inflammatory or mass-effect findings; testing is generally unnecessary when alarm features are absent.
The trap
A common pitfall is over-imaging every recurrent headache while missing migraine-specific treatment. The resolving clue is stable recurrent pattern with normal neurologic exam and no red flags, which supports outpatient migraine or tension management.
The repair move
Next best step: screen for red flags first, then treat acute migraine with NSAID or triptan based on severity and contraindications; for frequent disabling attacks, start preventive therapy such as propranolol 40 mg twice daily or topiramate 25 mg nightly titrated upward. Use simple analgesics and stress or sleep counseling for tension headache.
Try a free question
CoreA 30-year-old woman has recurrent unilateral pulsatile headaches with nausea and photophobia; neurologic exam is normal and there are no red flags. What is the next best step in management?
Show answer and explanation
Answer: A. Treat as migraine with acute NSAID or triptan therapy. Typical primary migraine without red flags is treated clinically with targeted acute therapy.
Why the other choices are tempting
- B. Urgent MRI is unnecessary without red flags or focal findings.
- C. Opioids are not first-line and increase risk of medication overuse headache.
- D. Steroids are not routine first-line treatment for uncomplicated migraine.
- E. EEG is not indicated for straightforward primary headache phenotype.
Flashcards
Tap a card to flip it.
Which associated symptom most strongly favors migraine over tension headache?
Nausea, with or without photophobia or phonophobia, strongly favors migraine.
What pain quality is typical of tension headache?
Bilateral pressing or tightening discomfort without prominent nausea.
Quick answers
What is the fastest way to tell Migraine from Tension headache?
Nausea or photophobia accompanying headache is the quickest discriminator favoring migraine over tension headache.
What is the key clue for Migraine?
Recurrent unilateral pulsatile headache with nausea and photophobia, often worsened by activity, supports migraine.
What is the key clue for Tension headache?
Bilateral pressing band-like pain without nausea or focal neurologic findings supports tension headache.
What is the common trap with Migraine vs Tension headache?
A common pitfall is over-imaging every recurrent headache while missing migraine-specific treatment. The resolving clue is stable recurrent pattern with normal neurologic exam and no red flags, which supports outpatient migraine or tension management.