Educational scope notice: This is a study note for medical students, not medical advice, diagnosis, or treatment guidance. Clinical management should follow local protocols and current guidelines.
Migraine, tension-type headache, and cluster headache are the three primary patterns most often confused. The fastest separation compares pain quality, duration, associated symptoms, behavior during the attack, and treatment clues.
| Feature | Migraine | Tension-type headache | Cluster headache |
|---|---|---|---|
| Usual laterality | Often unilateral, but can be bilateral | Usually bilateral | Strictly unilateral |
| Pain quality | Pulsating or throbbing | Pressing or tightening | Excruciating orbital, supraorbital, or temporal pain |
| Intensity | Moderate to severe | Mild to moderate | Very severe |
| Duration | 4–72 hours | 30 minutes to 7 days, or chronic | 15–180 minutes |
| Activity | Routine activity worsens pain | Not worsened by routine activity | Patient is often restless or pacing |
| Nausea and vomiting | Common | Not typical; vomiting argues against it | May occur, but autonomic signs dominate |
| Light and sound sensitivity | Photophobia and phonophobia common | At most one of photophobia or phonophobia in many criteria | Not the main discriminator |
| Autonomic signs | Not the defining feature | Absent | Ipsilateral tearing, red eye, nasal symptoms, sweating, small pupil, drooping eyelid |
| Acute treatment clue | NSAIDs or triptans | Simple analgesics, avoid overuse | Oxygen or sumatriptan |
| Preventive clue | Topiramate, beta-blockers, amitriptyline, botulinum toxin, CGRP monoclonal antibodies | Usually lifestyle, trigger, and analgesic-overuse strategy | Verapamil classically |
Rapid bedside separation
If the patient wants to lie still in a dark room and has nausea, think migraine. If the patient has bilateral pressure without nausea and can keep functioning, think tension-type headache. If the patient is pacing with a red tearing eye and severe unilateral orbital pain, think cluster headache.
One caution prevents the most common misstep: do not diagnose tension-type headache just because the pain is bilateral. Nausea, vomiting, worsening with movement, and severe disability pull the answer back toward migraine. Each pattern in full is covered in /notes/neurology/headache-clinical-presentation/, with diagnostic criteria in /notes/neurology/headache-diagnosis/.
Evidence anchors
- Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition: https://ichd-3.org/
- NICE. Headaches in over 12s: diagnosis and management (CG150): https://www.nice.org.uk/guidance/cg150