How can I differentiate between tension-type headaches and other types of headaches, such as migraines or cluster headaches?

Differentiating between tension-type headaches, migraines, and cluster headaches involves assessing specific features of the headache, as outlined in UK clinical guidelines ¹. 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 ¹,².

• Pain Location:
  • Tension-type headache: Typically bilateral ¹.
  • Migraine: Can be unilateral or bilateral ¹.
  • Cluster headache: Unilateral, often located around the eye, above the eye, and along the side of the head/face ¹.
• Pain Quality:
  • Tension-type headache: Described as pressing or tightening, and non-pulsating ¹.
  • Migraine: Often pulsating, described as throbbing or banging, particularly in young people aged 12 to 17 years ¹.
  • Cluster headache: Variable, can be sharp, boring, burning, throbbing, or tightening ¹.
• Pain Intensity:
  • Tension-type headache: Mild or moderate ¹.
  • Migraine: Moderate or severe ¹.
  • Cluster headache: Severe or very severe ¹.
• Effect on Activities:
  • Tension-type headache: Generally not aggravated by routine activities of daily living ¹.
  • Migraine: Aggravated by, or causes avoidance of, routine activities of daily living ¹.
  • Cluster headache: Often associated with restlessness or agitation ¹.
• Other Symptoms:
  • Tension-type headache: Typically no other associated symptoms ¹.
  • Migraine: May include unusual sensitivity to light (photophobia) and/or sound (phonophobia), or nausea and/or vomiting ¹. 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 ¹.
  • 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 ¹.
• Duration of Headache:
  • Tension-type headache: Can last from 30 minutes to continuous ¹. 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 ¹.
  • Migraine: Lasts 4 to 72 hours in adults, and 1 to 72 hours in young people aged 12 to 17 years ¹. 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 ¹.
  • Cluster headache: Typically lasts 15 to 180 minutes ¹. Episodic cluster headaches occur from once every other day to 8 times a day with a pain-free period of more than 1 month ¹. 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 ¹.

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 ¹. 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 ¹. If there is uncertainty about the diagnosis or atypical symptoms, specialist advice or referral to neurology should be considered ²,³.