Updated October 2025
Headache Evaluation
Differentiating Migraine, Tension-Type, and Secondary Headaches
Clinically distinguish migraine from tension-type headache (TTH) using International Classification criteria, targeted history, and focused neurologic examination. Systematically screen for secondary “red flags” that mandate urgent imaging or specific testing. Evidence indicates TTH is more prevalent but migraine is more disabling; accurate phenotyping guides acute and preventive therapies.
Clinical question
How should clinicians evaluate headache to differentiate migraine, tension-type headache, and secondary causes in adults?
HeadacheMigraineTension-Type HeadacheSecondary HeadacheEmergency MedicinePrimary CareNeurologyICHD
Key points
First, rule out secondary causes
Use red flags (onset, age, fever, immunosuppression, cancer, focal deficits, papilledema, altered mental status, thunderclap, pregnancy/postpartum, neck stiffness). Abnormal vitals (fever) make primary migraine/TTH unlikely [5], [2], [3].
Then phenotype primary headache
Migraine: recurrent attacks, unilateral throbbing, moderate–severe, aggravated by activity, nausea and/or photo/phonophobia. TTH: bilateral pressing/tightening, mild–moderate, not worsened by activity, no nausea; at most one of photophobia or phonophobia [1], [2], [6].
Apply ICHD criteria
Use standardized diagnostic features and attack frequency to classify episodic vs chronic forms and to separate TACs and other primaries from migraine/TTH [1], [7], [2].
Recognize epidemiology and overlap
TTH is most prevalent; migraine often coexists and shares triggers (stress, sleep disruption). Mixed phenotypes occur; manage to the dominant features [8], [1], [9].
Management hinges on diagnosis
Migraine: NSAIDs, triptans, gepants, lasmiditan; TTH: simple analgesics, NSAIDs, non-pharmacologic measures. Preventives depend on frequency/disability [4], [10], [6].
Evidence highlights
TTH ~40%, Migraine ~10% [1]
Global prevalence
Most headaches are primary; exclude red flags first [2], [3]
Primary vs secondary
Migraine most disabling primary headache [4]
Disability
Stepwise Evaluation of Headache
A structured approach improves accuracy and safety while minimizing unnecessary imaging.
1
Screen for secondary red flags
Ask about thunderclap onset, age >50 at onset, cancer, immunosuppression, fever/meningismus, pregnancy/postpartum, anticoagulation, recent head/neck trauma, positional or Valsalva-related change, progressive pattern, focal neurologic deficits, seizures, visual changes/papilledema. Fever argues against migraine/TTH and suggests infection/inflammation [5], [2], [3].
2
Perform focused exam
Vital signs, complete neurologic exam, funduscopic exam for papilledema, temporalis/scalp tenderness, neck stiffness, TMJ, and cranial nerves. Abnormal exam increases likelihood of secondary cause and need for urgent imaging [2], [3].
3
Classify headache type using ICHD features
Differentiate migraine vs TTH by pain quality, intensity, laterality, triggers, associated symptoms, and impact on activity. Consider TACs if short, severe unilateral attacks with autonomic signs; daily persistent headache and medication overuse if chronic pattern [1], [7], [2], [6].
4
Order targeted tests only when indicated
Neuroimaging (CT/MRI) for red flags or abnormal exam; lumbar puncture for thunderclap with negative CT, suspected meningitis/IIH; ESR/CRP for suspected GCA in older adults; pregnancy testing where relevant [5], [2], [3].
5
Document frequency and disability
Track monthly headache days, acute medication days, and functional impact to guide acute vs preventive treatment and identify medication overuse [4], [2], [6].
Key Differentiators: Migraine vs Tension-Type vs Secondary
Use the following features to distinguish primary headaches and to identify when a secondary etiology is more likely.
Migraine (without aura) — ICHD features
Recurrent attacks 4–72 h, untreated [1], [7]
≥2 of: unilateral, pulsating, moderate–severe, aggravated by routine activity [1], [7]
During headache: nausea/vomiting or photophobia AND phonophobia [1], [7]
Often prodrome, triggers (stress, menses), and disability; most disabling primary headache [4]
Tension-Type Headache — ICHD features
Duration 30 min–7 days (episodic); ≥15 days/month for chronic [1], [7]
≥2 of: bilateral, pressing/tightening (nonpulsating), mild–moderate, not aggravated by routine activity [1], [7], [2]
No nausea/vomiting; at most one of photophobia or phonophobia [1], [7]
High population prevalence; wide published range historically [8], [1]
When to suspect TACs or other primaries
Short, severe unilateral attacks with ipsilateral autonomic features (tearing, ptosis) suggest cluster or TACs; rare vs migraine/TTH [1], [2]
Daily new persistent headache onset to constant pain—consider NDPH [1], [2]
Secondary headache red flags (imaging/labs)
Thunderclap onset; CT head ± CTA; LP if CT negative [5], [2], [3]
Fever/neck stiffness; evaluate for CNS infection [5], [2]
Cancer, HIV/immunosuppression; consider opportunistic infection/metastasis [2], [3]
Age >50 with new headache; check ESR/CRP for GCA [2], [3]
Papilledema or focal deficits; MRI/MRV for mass/IIH/CVT [2], [3]
Pregnancy/postpartum; evaluate preeclampsia, RCVS, CVT [2], [3]
Medication overuse considerations
Overuse thresholds: simple analgesics ≥15 d/mo; triptans/combination/opioids ≥10 d/mo [1], [2]
Suspect if chronic daily pattern with reduced acute efficacy; requires withdrawal and prevention [1], [2]
Clinical Features at a Glance
Contrasting features that most efficiently separate migraine from TTH.
Pain characteristics
Migraine: throbbing/pulsatile; unilateral; moderate–severe; worsened by activity [1], [6]
TTH: pressing/tightening; bilateral; mild–moderate; not worsened by activity [1], [6]
Temporal pattern
Migraine: 4–72 hours, episodic ± progression to chronic [1], [7]
TTH: 30 min–7 days; chronic if ≥15 d/mo for >3 months [1], [7]
Associated symptoms
Migraine: nausea/vomiting common; photophobia and phonophobia together are typical [1], [7]
TTH: no nausea/vomiting; at most one of photophobia or phonophobia [1], [7]
Epidemiology and impact
TTH most prevalent globally (~40%); migraine ~10% [1]
Migraine drives greater disability and healthcare use [11], [4]
Linking Diagnosis to Management
Choosing acute and preventive treatments relies on precise classification.
1
Acute migraine
Use NSAIDs or acetaminophen for mild–moderate attacks; triptans for moderate–severe; consider gepants or lasmiditan when triptans are contraindicated or ineffective. Limit acute meds to avoid overuse [4], [6].
2
Acute TTH
Simple analgesics (acetaminophen, NSAIDs) are first line; avoid opioids and combinations that raise medication overuse risk. Address triggers and ergonomics [1], [10].
3
Prevention
Indicated for frequent or disabling attacks; choice guided by comorbidity and phenotype. Nonpharmacologic measures (sleep, stress management, exercise) are foundational [4], [10], [6].
References
Source material
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