How can I differentiate between tension-type headaches and migraines in a primary care consultation?

To differentiate between tension-type headaches and migraines during a primary care consultation, focus on the following clinical features:

• Pain location: Tension-type headaches typically present with bilateral pain, whereas migraines often have unilateral or bilateral pain.
• Pain quality: Tension-type headaches are described as pressing or tightening and non-pulsating, while migraines usually have a pulsating, throbbing, or banging quality.
• Pain intensity: Tension-type headaches are generally mild to moderate in intensity, whereas migraines are moderate to severe.
• Effect on activities: Tension-type headaches are not aggravated by routine activities of daily living, but migraines are aggravated by or cause avoidance of such activities.
• Associated symptoms: Migraines often have associated symptoms such as nausea, vomiting, and unusual sensitivity to light and/or sound, which are absent in tension-type headaches.
• Aura symptoms: Migraines may be preceded or accompanied by aura symptoms (visual disturbances like flickering lights or spots, sensory symptoms like numbness or pins and needles, or speech disturbances) that develop gradually over at least 5 minutes and last 5 to 60 minutes; these are not features of tension-type headaches.
• Duration: Tension-type headaches can last from 30 minutes to continuous, whereas migraines typically last 4 to 72 hours in adults.

Using a headache diary to record frequency, duration, severity, associated symptoms, and triggers over at least 8 weeks can aid differentiation, especially if co-existing headache types are suspected.

Always consider red flags and refer if atypical features or neurological deficits are present.

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