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 ^[10], ^[12], ^[14].

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 ^[4], ^[12], ^[15].

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 ^[4], ^[7], ^[12].

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 ^[1], ^[4], ^[16].

Management hinges on diagnosis

Migraine: NSAIDs, triptans, gepants, lasmiditan; TTH: simple analgesics, NSAIDs, non-pharmacologic measures. Preventives depend on frequency/disability ^[9], ^[13], ^[15].

Evidence highlights

TTH ~40%, Migraine ~10% ^[4]

Global prevalence

Most headaches are primary; exclude red flags first ^[12], ^[14]

Primary vs secondary

Migraine most disabling primary headache ^[9]

Disability

Clinical Workflow

Stepwise Evaluation of Headache

A structured approach improves accuracy and safety while minimizing unnecessary imaging.

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 ^[10], ^[12], ^[14].

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 ^[12], ^[14].

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 ^[4], ^[7], ^[12], ^[15].

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 ^[10], ^[12], ^[14].

Document frequency and disability

Track monthly headache days, acute medication days, and functional impact to guide acute vs preventive treatment and identify medication overuse ^[9], ^[12], ^[15].

Diagnostic Criteria

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 ^[4], ^[7]

≥2 of: unilateral, pulsating, moderate–severe, aggravated by routine activity ^[4], ^[7]

During headache: nausea/vomiting or photophobia AND phonophobia ^[4], ^[7]

Often prodrome, triggers (stress, menses), and disability; most disabling primary headache ^[9]

Tension-Type Headache — ICHD features

Duration 30 min–7 days (episodic); ≥15 days/month for chronic ^[4], ^[7]

≥2 of: bilateral, pressing/tightening (nonpulsating), mild–moderate, not aggravated by routine activity ^[4], ^[7], ^[12]

No nausea/vomiting; at most one of photophobia or phonophobia ^[4], ^[7]

High population prevalence; wide published range historically ^[1], ^[4]

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 ^[4], ^[12]

Daily new persistent headache onset to constant pain—consider NDPH ^[4], ^[12]

Secondary headache red flags (imaging/labs)

Thunderclap onset; CT head ± CTA; LP if CT negative ^[10], ^[12], ^[14]

Fever/neck stiffness; evaluate for CNS infection ^[10], ^[12]

Cancer, HIV/immunosuppression; consider opportunistic infection/metastasis ^[12], ^[14]

Age >50 with new headache; check ESR/CRP for GCA ^[12], ^[14]

Papilledema or focal deficits; MRI/MRV for mass/IIH/CVT ^[12], ^[14]

Pregnancy/postpartum; evaluate preeclampsia, RCVS, CVT ^[12], ^[14]

Medication overuse considerations

Overuse thresholds: simple analgesics ≥15 d/mo; triptans/combination/opioids ≥10 d/mo ^[4], ^[12]

Suspect if chronic daily pattern with reduced acute efficacy; requires withdrawal and prevention ^[4], ^[12]

Comparative Phenotype

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 ^[4], ^[15]

TTH: pressing/tightening; bilateral; mild–moderate; not worsened by activity ^[4], ^[15]

Temporal pattern

Migraine: 4–72 hours, episodic ± progression to chronic ^[4], ^[7]

TTH: 30 min–7 days; chronic if ≥15 d/mo for >3 months ^[4], ^[7]

Associated symptoms

Migraine: nausea/vomiting common; photophobia and phonophobia together are typical ^[4], ^[7]

TTH: no nausea/vomiting; at most one of photophobia or phonophobia ^[4], ^[7]

Epidemiology and impact

TTH most prevalent globally (~40%); migraine ~10% ^[4]

Migraine drives greater disability and healthcare use ^[6], ^[9]

Therapeutic Implications

Linking Diagnosis to Management

Choosing acute and preventive treatments relies on precise classification.

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 ^[9], ^[15].

Acute TTH

Simple analgesics (acetaminophen, NSAIDs) are first line; avoid opioids and combinations that raise medication overuse risk. Address triggers and ergonomics ^[4], ^[13].

Prevention

Indicated for frequent or disabling attacks; choice guided by comorbidity and phenotype. Nonpharmacologic measures (sleep, stress management, exercise) are foundational ^[9], ^[13], ^[15].

References

Source material

Primary literature that informs this article.