Confusable diagnoses · PANCE / PANRE

Migraine vs Tension-Type Headache

Written & clinically reviewed by Ryan Busch, PA-C · Updated August 2026 · Report an error

Migraine and Tension-Type Headache are easy to mix up on the boards. Here's a side-by-side comparison — presentation, workup, imaging, and first-line treatment — drawn from our full outlines.

Migraine vs Tension-Type Headache at a glance

  • Migraine: Recurrent primary headache disorder with unilateral throbbing pain, photophobia, nausea.
  • Tension-Type Headache: Most common primary headache; bilateral pressing/tightening, mild-moderate, no nausea.

Try two board-style questions on Migraine vs Tension-Type Headache

Real questions from the FirstPassPA bank, with the full explanation. Pick an answer — no signup, no email.

Question 1NeurologyEasy
A 32-year-old woman has 8 migraine days per month despite trials of sumatriptan and naproxen. She has tried propranolol and topiramate without benefit and would like to start preventive therapy that targets the calcitonin gene-related peptide pathway. Which of the following is the most appropriate medication?
  • AErenumab
  • BOnabotulinumtoxin A
  • CVerapamil
  • DAmitriptyline
Reveal answer & full explanation
Correct answer: A — Erenumab
  • AErenumab✓
  • BOnabotulinumtoxin A
  • CVerapamil
  • DAmitriptyline

Why erenumab is correct

  • Calcitonin gene-related peptide (CGRP) monoclonal antibodies — including erenumab, fremanezumab, galcanezumab, and eptinezumab — are FDA-approved for episodic and chronic migraine prevention and specifically target the CGRP pathway.
  • They reduce migraine days by ~50% in roughly half of patients, with excellent tolerability and no CNS side effects.
  • Most are monthly subcutaneous injections; eptinezumab is administered intravenously quarterly.

Why the others are wrong

  • B) OnabotulinumtoxinA — FDA-approved for chronic migraine prevention (≥15 headache days/month) but does not target the CGRP pathway; this patient has 8 migraine days/month (episodic migraine).
  • C) Verapamil — Used for cluster headache prevention, not the preferred agent for migraine and does not target the CGRP pathway.
  • D) Amitriptyline — A tricyclic antidepressant used as migraine prophylaxis but does not target the CGRP pathway, which is what the patient specifically requests.

Additional high-yield points

  • Gepants (ubrogepant, rimegepant) are CGRP receptor antagonists used for acute treatment and, for some agents, prevention.
Question 2NeurologyMedium
A 28-year-old woman presents with a 6-month history of bilateral, band-like, pressing (non-pulsatile) headaches occurring 2-3 times per week and lasting 4-6 hours. The pain is mild to moderate, is not worsened by routine activity, and is not associated with nausea, vomiting, photophobia, or phonophobia. Neurologic exam is normal. She has not previously tried any therapy. Which of the following is the most appropriate first-line treatment for her acute headaches?
  • AOral ibuprofen
  • BOral sumatriptan
  • COral verapamil
  • DOral butalbital
Reveal answer & full explanation
Correct answer: A — Oral ibuprofen
  • AOral ibuprofen✓
  • BOral sumatriptan
  • COral verapamil
  • DOral butalbital

Why oral ibuprofen is correct

  • Episodic tension-type headache is the most common primary headache disorder: bilateral, pressing or tightening (non-pulsatile) pain of mild to moderate intensity, not aggravated by routine physical activity, and without nausea or significant photophobia/phonophobia
  • First-line acute therapy is a simple analgesic — NSAIDs (ibuprofen, naproxen) or acetaminophen — with NSAIDs generally preferred for efficacy, per current AAFP and international headache society guidance
  • Patients should be counseled to limit use to fewer than 10–15 days/month to avoid medication-overuse headache

Why the others are wrong

  • Oral sumatriptan — 5-HT1B/1D agonist for acute migraine; triptans are not effective for tension-type headache. Trap: buzzword-matching recurrent headache to migraine despite the stem excluding every migraine feature (pulsatile quality, nausea, photophobia/phonophobia, activity aggravation)
  • Oral verapamil — calcium channel blocker used for cluster headache prophylaxis; it is neither an acute therapy nor a tension-type headache drug. Trap: right-drug-wrong-disease plus prophylaxis-versus-acute confusion
  • Oral butalbital — butalbital-containing combination analgesics are specifically discouraged for tension-type headache because of sedation, dependence, and a high rate of medication-overuse headache; they are never the opening move in a patient who has tried no therapy. Trap: escalating to a sedative combination pill before a simple analgesic has been tried

Additional high-yield points

  • For frequent or chronic tension-type headache, amitriptyline is first-line prophylaxis
🔒 Free preview limit reached

Keep comparing — start your free trial

You've used your 2 free previews. Create your free account to see the full Migraine vs Tension-Type Headache comparison — plus all 514 diagnosis outlines, 7,200+ board-style questions, and an AI tutor. Your 7-day free trial includes everything, no credit card required.

Start your 7-day free trial → Sign in
Free to start · No credit card · Cancel anytime

Side-by-side comparison

FeatureMigraineTension-Type Headache
At a glanceRecurrent primary headache disorder with unilateral throbbing pain, photophobia, nausea.Most common primary headache; bilateral pressing/tightening, mild-moderate, no nausea.
Classic presentationPOUND mnemonic: Pulsatile, One-day duration (4-72 h), Unilateral, Nausea, Disabling — 4 of 5 features highly suggest migraine.; Prodrome (hours-days before): mood changes, food cravings, neck stiffness, yawning, urinary frequency; Aura (~25%): visual (scintillating scotoma, fortification spectra, hemianopia), sensory (paresthesias…Bilateral, non-throbbing, mild-moderate, without autonomic or migrainous features.; Bilateral 'band-like' pressing or tightening pain; Mild to moderate intensity (does not preclude activities); Duration 30 min to 7 days; NO nausea/vomiting; At most one of photophobia or phonophobia; Not aggravated by routine physical activity (unlike…
Workup / key labsICHD-3 criteria for migraine without aura: ≥5 attacks lasting 4-72 hours, with ≥2 of [unilateral, pulsating, moderate-severe, aggravated by activity] AND ≥1 of [nausea/vomiting, photophobia + phonophobia]. Migraine with aura: ≥2 attacks of fully reversible aura symptoms (most often visual, sensory, or speech/language) with typical…ICHD-3: ≥10 episodes lasting 30 min-7 days, with ≥2 of [bilateral, pressing/tightening, mild-moderate, not aggravated by activity] AND no nausea/vomiting AND ≤1 of [photophobia, phonophobia].; Not routinely indicated; ESR/CRP if temporal arteritis suspected (age >50)
ImagingNeuroimaging NOT routinely indicated for typical migraine with normal exam; MRI brain indicated for: red flags (SNOOP: Systemic symptoms/Secondary risk factors, Neurologic signs, Onset sudden/thunderclap, Older age >50 with new headache, Pattern change/Progressive/Positional/Precipitated by Valsalva); Lumbar puncture if SAH or…Not indicated for typical TTH with normal exam; MRI brain only if red flags (SNOOP — systemic, neurologic, onset, older age, pattern change)
First-line treatmentAbortive: NSAIDs (ibuprofen 400-800 mg, naproxen 500 mg) for mild-moderate attacks; Triptan (5-HT1B/1D agonist: 1B causes cranial vasoconstriction, the basis of its cardiovascular contraindications; 1D inhibits trigeminal CGRP and substance P release) — sumatriptan 50-100 mg PO (also 6 mg SC, 20 mg nasal), rizatriptan 10 mg, eletriptan…NSAIDs — ibuprofen 400-800 mg, naproxen 500 mg — first-line for acute treatment; Acetaminophen 1000 mg — alternative; less effective than NSAIDs; Aspirin 650-1000 mg; Combination analgesics (acetaminophen-aspirin-caffeine) — effective but increase risk of medication overuse headache; Limit acute medications to <2 days/week to prevent…

Drill Migraine vs Tension-Type Headache questions on FirstPassPA

Turn this comparison into retention. 7,200+ board-style questions with an AI tutor that explains every answer — free to start, no card required.

Answer the 2 free questions above → Get today's free question →

Full outlines

Migraine Tension-Type Headache All 514 diagnoses

Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.