Approximately 99% of all headaches that mankind suffers are either Tension Type Headache (TTH) or Migraine. Tension Type Headache relates to generalized anxiety disorder (GAD) while Migraine may link to GAD or depression. Tension Type Headache is 70% of Headache and Migraine is 30% of headache.

The eternal clinical problem is how does one tell them apart?

**Tension Type Headache in forehead and neck**

Migraine and Tension Type Headache are differentiated by a headache history. Usually the neurologic exam and brain MRI scan are normal. Migraines are usually one-sided, throbbing, moderate to severe, and may be associated with nausea, vomiting, and sensitivity to light and noise.

Tension Type Headaches are described as tight or squeezing, may be bitemporal, and are mild to moderate. They have no other distinguishing features.

Related questions

What does the Bible of headache, the International Classification of Headache Disorders say?

Migraine without aura is diagnosed by a headache pattern fulfilling the following criteria:

A) At least five attacks fulfilling B-D.

B) Attacks lasting 4-72 hours (untreated or unsuccessfully treated).

C) At least two of the following characteristics:

1. Unilateral (one sided) location.

2. Pulsating (throbbing) quality.

3. Moderate or severe intensity (inhibits or prohibits daily activities).

4. Aggravation by walking stairs or similar routine activity.

D) At least one of the following:

1. Nausea and/or vomiting.

2. Photophobia (sensitivity to light) and phonophobia (sensitivity to sound).

Diagnosing Tension Type Headache.

Stress and mental tension are common triggers.

Symptoms include dull, non-pulsatile, bilateral, constricting pain (not severe); pericranial tenderness is common. Palpation of the head may be painful and is a helpful clinical sign.

Unlike migraine, there is no significant nausea, no vomiting, and a lack of aggravation by routine physical activity.

It may help to read my article, “What is Migraine?” on my website, www.doctormigraine.com.

Tension-type headaches can be either episodic or chronic, are not usually disabling, and patients usually do not seek medical care and usually successfully self-treat. The attacks are generalized throughout the head but may involve the frontal and occipital regions. The pain is described as being like a 'tight band' around the head. It does not worsen with routine physical activity.

This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, migraine textbook author, podcaster, YouTube video producer, and blogger.

What are the clinical characteristics of Migraine and Tension Type Headache?

Migraine is usually one-sided 80% of the time while Tension Type Headache is on both sides of the head. Any severe headache bad enough to cause someone to go down for work or social activities or to consider or go to the Emergency is Migraine or some other severe medical problem requiring doctor examination and brain scanning.

Tension Type Headache occurs on both sides of the head, and is described as pressing or tight, like a vise, or like a band around the head, and only mild or moderate in severity. On a scale of 1-10 Tension Type Headache can only go to level 5. Patients with TTH may carry tension in their neck or shoulders and have muscle spasm knots in the back of their neck. Manual palpation of pericranial muscles may reveal tenderness, which is the most common abnormal finding in TTH.

Migraine may be severe headache and can be a 10 on a 1-10 scale. Migraine affects women 3X more than men and usually occurs between the ages of a teenager through late forties. Migraine comes with nausea, vomiting, throbbing or pulsating, sensitivity to light and sound and odors. The patient wants to go to sleep in a quiet, dark room. An episode of migraine may last 3-72 hours.

Migraine without aura used to be called “common” migraine because it is the most prevalent type of migraine, consisting of about 70% of all attacks of migraine. Primary headache means no organic cause for the headache can be determined. With migraine typically the patient has one sided headache (migraine comes from the Latin word meaning half of head or hemicrania), nausea and vomiting, photophobia (fear of light), or sonophobia (fear of sounds).

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Related questions

Are there other lay names for migraine? Migraine may be called sick headache, sinus headache, heat or sun headache, menstrual headache, letdown headache (a headache that comes during a weekend, vacation, or holiday), cold front or weather change headache (from a drop in the barometric pressure), or nocturnal headache (middle of the night, end of a dream headache.)

The patient may not know he has migraine because he has called his headache one of these wrong terms, he finally comes to the doctor for treatment and diagnosis of headache.

TTH is called stress headache, muscle contraction headache, and normal headache.

What is Sick headache? Hippocrates, the philosopher and physician first described a headache type associated with nausea, feeling upset in the stomach, or actually vomiting 400 years before Christ. Human beings have a chemoreceptive zone in the base of the brain just below the pons, called the “vomit center,” Simulation of this area will produce nausea and vomiting. This location near the pons and the eighth cranial nerve brings vestibular or balance and movement detection information into the brain. Motion sickness, and migraine nausea, Meniere’s disease, and vestibular migraine all pass through this area. TTH doesn’t cause nausea or vomiting.

What is “Sinus headache? Sinus headache is a misnomer, or an inaccurate term. That makes sense because it was invented by the pseudofed business in the 1950’s and who hasn’t seen their TV ads of frontal check-sinus located headache? However, the phrase “sinus headache” is not in the International Classification of Headache Disorders II and is a market term made up by the pseudofed industry to sell pseudofed. Pseudofed is the ingredient that is changed in a home drug lab to methamphetamine an addictive narcotic. The cop on the street calls methamphetamine, “speed.”

They have done a good job because there are now more than 200 pseudofed drugs in America. The situation is that the migraine process causes dilatation of cerebral arteries and caffeine and pseudofed which are available over the counter are weak vasoconstrictors. So, pseudofed is mildly effective for treating migraine, but it can aggravate medication overuse headache, cause tachycardia and insomnia, and make persons who take it feel “wired” like 10 cups of coffee.

Read my article, “Sinus, Allergy, or Migraine Headache” on my website, www.doctormigraine.com.

Dr. David Dodick, chief of the section of headache at the Mayo Clinic wrote an article several years ago wherein he interviewed 100 patients, referred to the Mayo Clinic, who thought they had “sinus headache.” After taking a history, examining these patients and doing testing, Dr. Dodick thought that 97 of them had either migraine or migraine and medication overuse headache. He thought that 3 of them had “acute rhinosinusitis,” an infection of the sinus, treated with an antibiotic. The 97 patient migraine group had normal sinus CAT scans and nasal congestion but no green, purulent nasal discharge. I think that sinus headache is seldom thought to be Tension Type Headache since it is not usually in the maxillary check area and doesn’t cause nasal congestion.

What is Nocturnal headache? Migraine headache may start in the middle of the night and commonly comes “at the end of a dream.” During dreaming the autonomic nervous system turns on and t heir is vasoconstriction of the cerebral arteries. During dreaming there is rapid eye movement REM sleep which suddenly shuts off at the end of dreaming like a light switch and the cerebral arteries vasodilate and the patient wakes up with a migraine headache.

Forty percent of migraine headache patients have GAD and 50% have depression, both of which can have insomnia conditions. TTH is also tied to generalized anxiety disorder, GAD, and has sleep disorder or insomnia as a common cardinal symptom.

These anxious or depressed patients have initial trouble going to sleep, which means they cannot fall asleep easily. They also may have trouble maintaining sleep, so that they wake up multiple times during the night.

What is Heat or sun headache? Heat or the sun causes dilation of cerebral arteries. Recall how someone who is hot has facial flushing with facial arterioles dilated, giving the characteristic red face appearance. Heat, such as a hot towel on the neck or forehead may help TTH.

What is Menstrual headache? Withdrawal from estrogen for women after the 3rd week of their cycle may give a migraine headache in 70% of migraine headaches. Estrogen birth control pills, IUDs with estrogen, estrogen patches, and estrogen pellets may all aggravate migraine.

TTH has no estrogen connection.

What about Let down headache? Situations of letting down from stress, like vacations, holidays, or weekends such as Saturday or Sunday are common times for migraine headache attacks. This is because the migraine patient is withdrawing from the stress hormone adrenalin which promotes vasoconstriction of cerebral arteries. Rebound vasodilation occurs during the letdown period promoting migraine.

TTH may in general get better with freedom from stress and worse with stress. Like a hard-working businessman has TTH intermittently during the stress of his work week, but is headache free during a vacation to Colorado in the summer.

What is Barometric pressure change or cold front headache? Human beings have barometric sensors that can cause cerebral arterial dilation and initiation of a migraine headache. TTH has no prominent relationship to barometric pressure.

Can a person have both Tension Type Headache and Migraine? Yes, this is pretty common since migraine and Tension Type Headache are comorbid with GAD 40% of the time. There is some data that reports some headaches start of as a mild Tension Type Headache and then accelerate into a migraine headache.

Is acute treatment for Tension Type Headache different from treating Migraine? Migraine should be treated early, at prodrome if possible, which can come 24 hours before the actual attack of a migraine. It may be hard for a person to identify prodrome, but the symptoms may be yawning, depression, need to urinate often, photophobia, phonophobia, or trouble concentrating.

Tension type headache doesn’t have a prodrome like this but may relate to stress. However, migraine also may come with stress, or after stress.

Migraine should be treated at onset of headache pain with a triptan. There are 7 triptans-sumatriptan oral, nasal spray, or subcutaneous injection, zomatriptan oral or nasal spray, rizatriptan oral, eletriptan, almotriptan, naratriptan, and frovatriptan. If treated early, at onset of migraine, these drugs block the release of the inflammatory neurochemicals and stop migraine headache. Pain killers can’t do this. Butalbital and opioid drugs should never be used for migraine or Tension Type Headache.

New drugs for acute migraine therapy are Nurtec, Qulipta, Reyvow, Ubrevly, and Trudhesa.

Tension Type Headache may be treated with aspirin 500-1000 mg or an NSAID. NSAID means non-steroidal anti-inflammatory drug and includes Advil, Aleve, or Celebrex. Combination pain killers with caffeine may be effective also. Tylenol (acetaminophen) is commonly used but evidence from controlled trials is mixed. Tylenol is better than placebo but inferior to NSAIDS. Chronic heartburn or gastric irritation may result from these drugs and may be treated by reducing dosing or taking Prilosec or similar drugs.

None of these drugs-triptans for migraine or NSAIDs for Tension Type Headache should be used more than 2 days a week, because more treatment days may cause medication overuse headache.

Since TTH is the most common type of headache it is usually self-managed. Unless TTH is chronic or disabling, which is rare, these patients don’t usually see a headache doctor.

Migraine is a much more concerning, potentially disabling medical condition, yet more than half of all migraine suffers are never diagnosed. The vast majority of migraine sufferers do not seek medical care for their pain and only 4% of migraine who seek medical care actually see a headache specialist. Although 25% of sufferers would benefit from preventive treatment, only 12% of all sufferers receive it.

What is the preventive treatment of Migraine and TTH? Migraine has had oral drugs indicated for treatment of migraine since Inderal (propranolol) was given an indication for prevention by the FDA in 1974. Common drugs that are used are propranolol, atenolol, amitriptyline or nortriptyline, topiramate, and valproic acid.

Newer and better preventive drugs for migraine are Aimovig, Ajovy, Emgality, and Vyepti. Nurtec ODT is the only drug for both acute and preventive therapy.

All these drugs are taken daily and orally and have considerable side effects-propranolol causing bradycardia, tiredness; amitriptyline and nortriptyline causing dry mouth, constipation, and weight gain; topiramate causing numb fingers, flat Coke taste, weight loss, word finding difficulty, and sedation.

All of these drugs may reduce migraine by 30-40 %, but many patients stop treatment due to side effects. Amitriptyline helps migraine patients who have trouble sleeping with generalized anxiety disorder and depression, which is common with migraine. Valproic acid and topiramate may produce teratogenic (baby harming) effects which limit their use in fertile women and migraine mainly strikes at the time women are fertile from teens to 45 or so.

**Oral TTH and migraine prevention; treats insomnia**

Migraine treatment has been greatly improved since 2018 with the introduction of 3 preventive drugs that block the CGRP neuropeptide. These drugs are Aimovig, Ajovy, and Emgality and they all have an indication from the FDA for migraine treatment. All of these drugs are given once a month by a subcutaneous injection in the anterior thigh or 2 inches from the belly button. Type 1 diabetics do this four times a day for life.

Persons with rare episodic tension-type headache don’t ask to see the doctor, but if the headaches become more intense or frequent, the situation may change. Chronic Tension Type Headache patients are more likely to see the doctor. In one study patients had daily or near daily headache for 7 years before consultation. Most of these patients were not disabled from working but their ability was greatly reduced. Many of these patients had severe anxiety or depression and needed psychiatric treatment.

Medication overuse headache may cause daily or near daily headache which is often in the back of the neck and may have migraine features such as nausea and sound and light sensitivity. This headache syndrome may be caused by taking over the counter pain killers such as NSAIDS or caffeine 15 or more times per month or by using opioid narcotics or butalbital 10 or more days per month.

Read about, “What is Medication Overuse Headache?” on my website, www.doctormigraine.com.

Amitriptyline has the best evidence of effectiveness of treatment for chronic TTH from randomised controlled trials. The dose is 75-150 mg/day. Amitriptyline decreases muscle tenderness. Adding tizanidine may improve its effect. Amitriptyline is also used for insomnia and for migraine prevention, making it a good drug for patients with mixed tension/migraine headache. Amitriptyline may have side effects of a dry mouth, morning sedation, constipation, and weight gain.

The headache benefits of amitriptyline are not thought to come from its antidepressant actions as the effective dose is generally lower than the dose needed to treat depression. Additionally, other drugs effective against depression, such as SSRIs (selective serotonin reuptake inhibitors), are not effective for tension-type headache.

Botox injections into pericranial muscles don’t improve TTH, but Biofeedback has evidence for success in treating TTH.

Read “Amitriptyline For Migraine,” on my website, www.doctormigraine.com.

What causes migraine and Tension Type headache? Much more research has been done on migraine than TTH and so migraine is better understood. The visual aura, sensory perceptions, and trouble speaking associated with migraine with aura is thought to relate to a wave of spreading depolarization of neuronal electrical activity spreading across the brain. The process usually starts in the occipital lobe at the back of the brain where visual images are processed and then spreads to the middle part of the brain where sensory sensations and speech is processed. TTH has no such visual, sensory, or language issues and a patient with migraine aura will immediately be placed in the migraine category as soon as the doctor hears about the aura.

The headache part of migraine relates to action in the brain where the brainstem activates the trigeminal sensory nerve which goes to the face or the back of the head at C2. This is the start of the headache part of migraine. Then within 20-40 minutes the ganglia of the trigeminal nerve and of cerebral arteries start to release the inflammatory neurochemicals-Neurokinan A, substance P, and CGRP. If taken early triptans prevent the release of these neurochemicals and that’s how they work. Then if the chemicals are released by 2 hours cerebral arterial vasodilation and the patient develops severe, one-sided, pulsatile pain as arterial blood pumped up to the brain by the heart stretches and inflames the cerebral arteries. By 4 hours into the migraine the neurochemicals inflame the thalamus, the human pain center, located deep in the brain.

The underlying cause of tension-type headache is not clear. Activation of hyperexcitable peripheral afferent neurons from head and neck muscles is one of the explanations for episodes of tension-type headache. Although muscle tenderness and psychological tension are associated with and aggravate tension-type headache they are not clearly its cause. There may be abnormalities in central pain processing and generalized increased pain sensitivity in some patients with TTH.

Tension Type Headache reference article

Loder, E. BMJ 2008;336:88-92 (12 January),Clinical Review Tension-type headache.

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All the best.

Britt Talley Daniel MD

Migraine Or Tension-Type Headache? 2023

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