Differentiating between tension-type headaches, migraines, and cluster headaches involves assessing specific features of the headache, as outlined in UK clinical guidelines NICE CG150. A headache diary can be a valuable tool to aid in diagnosis and to differentiate between headache types, especially when co-existing conditions like tension-type headache and migraine are suspected NICE CG150,NICE CKS.
- Pain Location:
- Tension-type headache: Typically bilateral NICE CG150.
- Migraine: Can be unilateral or bilateral NICE CG150.
- Cluster headache: Unilateral, often located around the eye, above the eye, and along the side of the head/face NICE CG150.
- Pain Quality:
- Tension-type headache: Described as pressing or tightening, and non-pulsating NICE CG150.
- Migraine: Often pulsating, described as throbbing or banging, particularly in young people aged 12 to 17 years NICE CG150.
- Cluster headache: Variable, can be sharp, boring, burning, throbbing, or tightening NICE CG150.
- Pain Intensity:
- Tension-type headache: Mild or moderate NICE CG150.
- Migraine: Moderate or severe NICE CG150.
- Cluster headache: Severe or very severe NICE CG150.
- Effect on Activities:
- Tension-type headache: Generally not aggravated by routine activities of daily living NICE CG150.
- Migraine: Aggravated by, or causes avoidance of, routine activities of daily living NICE CG150.
- Cluster headache: Often associated with restlessness or agitation NICE CG150.
- Other Symptoms:
- Tension-type headache: Typically no other associated symptoms NICE CG150.
- Migraine: May include unusual sensitivity to light (photophobia) and/or sound (phonophobia), or nausea and/or vomiting NICE CG150. Aura symptoms, such as flickering lights, spots, lines, partial vision loss, numbness, pins and needles, or speech disturbance, can occur with or without headache, developing over at least 5 minutes and lasting 5 to 60 minutes NICE CG150.
- Cluster headache: On the same side as the headache, symptoms can include a red and/or watery eye, nasal congestion and/or runny nose, swollen eyelid, forehead and facial sweating, and a constricted pupil and/or drooping eyelid NICE CG150.
- Duration of Headache:
- Tension-type headache: Can last from 30 minutes to continuous NICE CG150. Episodic tension-type headaches occur on fewer than 15 days per month, while chronic tension-type headaches occur on 15 or more days per month for over 3 months NICE CG150.
- Migraine: Lasts 4 to 72 hours in adults, and 1 to 72 hours in young people aged 12 to 17 years NICE CG150. Episodic migraines occur on fewer than 15 days per month, and chronic migraines occur on 15 or more days per month for over 3 months NICE CG150.
- Cluster headache: Typically lasts 15 to 180 minutes NICE CG150. Episodic cluster headaches occur from once every other day to 8 times a day with a pain-free period of more than 1 month NICE CG150. Chronic cluster headaches occur from once every other day to 8 times a day with a continuous pain-free period of less than 1 month in a 12-month period NICE CG150.
It is important to note that chronic migraine and chronic tension-type headache commonly overlap, and if any features of migraine are present, chronic migraine should be diagnosed NICE CG150. A headache diary should be used for a minimum of 8 weeks to record frequency, duration, severity, associated symptoms, medications taken, possible precipitants, and relationship to menstruation NICE CG150. If there is uncertainty about the diagnosis or atypical symptoms, specialist advice or referral to neurology should be considered NICE CKS,NICE CKS.