Migraine, tension-type headache, and cluster headache are the three primary headache patterns most often confused. A primary headache is a headache disorder in its own right rather than a symptom of another disease. The fastest separation compares pain quality, duration, associated symptoms, behavior during the attack, and treatment clues.
In the table, photophobia is light sensitivity, phonophobia is sound sensitivity, ipsilateral means on the same side as the pain, and CGRP is calcitonin gene-related peptide.
| 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 Headache Clinical Presentation, with diagnostic criteria in Headache Diagnosis. How common each pattern is, and so how likely it is before any testing, is the subject of Headache Epidemiology.