Tension-Type Headache and Cluster 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.
Tension-Type Headache vs Cluster Headache at a glance
Tension-Type Headache: Most common primary headache; bilateral pressing/tightening, mild-moderate, no nausea.
Cluster Headache: Severe unilateral periorbital headache with ipsilateral autonomic features; 'suicide headache.'
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Question 1NeurologyMedium
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
Question 2NeurologyEasy
A 28-year-old female has daily unilateral severe headaches around the right eye with ipsilateral tearing, rhinorrhea, and ptosis, each lasting 45-75 minutes, occurring at the same time (2 AM) for 4 weeks. She is normal between episodes. Which of the following is the most appropriate acute treatment?
ACarbamazepine
BHigh-flow oxygen
COral sumatriptan
DIndomethacin
Reveal answer & full explanation
Correct answer: B — High-flow oxygen
ACarbamazepine
BHigh-flow oxygen✓
COral sumatriptan
DIndomethacin
Why High-flow oxygen is correct
Cluster headache presents with strictly unilateral severe periorbital pain with ipsilateral autonomic features (lacrimation, rhinorrhea, ptosis, miosis, conjunctival injection), duration 15-180 minutes, occurring in clusters at the same time daily
Circadian pattern is often nocturnal due to hypothalamic activation
First-line acute treatment is high-flow 100% O2 via non-rebreather mask for 15-20 minutes
Subcutaneous sumatriptan 6 mg is the fastest pharmacologic acute alternative
Why the others are wrong
Carbamazepine — used for trigeminal neuralgia, not cluster headache (confused-with trigeminal neuralgia)
Oral sumatriptan — the oral route has too slow an onset for cluster headache; subcutaneous sumatriptan is the preferred pharmacologic acute option (right-concept-wrong-route)
Indomethacin — hallmark treatment for paroxysmal hemicrania, which has shorter attacks and an absolute indomethacin response, not cluster headache (confused-with paroxysmal hemicrania)
Additional high-yield points
Prophylaxis: verapamil (first-line); suboccipital steroid injection as a short-term bridge; lithium for chronic cluster; galcanezumab for episodic cluster
Distinguish from paroxysmal hemicrania: shorter duration (2-30 min), more frequent attacks, absolute indomethacin response
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Most common primary headache; bilateral pressing/tightening, mild-moderate, no nausea.
Severe unilateral periorbital headache with ipsilateral autonomic features; 'suicide headache.'
Classic presentation
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…
Severe unilateral periorbital pain + ipsilateral autonomic features + restlessness, attacks clustered in time.; Excruciating ('worst pain imaginable,' 'ice pick in the eye') unilateral periorbital/temporal pain; Duration 15-180 minutes per attack; Frequency: 1 every other day to 8 per day, often at the same time(s) daily; Cluster…
Workup / key labs
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)
ICHD-3: ≥5 attacks, severe unilateral orbital/supraorbital/temporal pain lasting 15-180 min (untreated), with ≥1 ipsilateral autonomic feature OR sense of restlessness, occurring once every other day to 8 per day.; Not typically helpful for diagnosis
Imaging
Not indicated for typical TTH with normal exam; MRI brain only if red flags (SNOOP — systemic, neurologic, onset, older age, pattern change)
MRI brain with pituitary protocol recommended at least once for all patients with cluster headache to exclude structural lesion (pituitary tumor, carotid lesion, AVM); Consider MRA if dissection suspected
First-line treatment
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…
Acute (abortive): high-flow 100% oxygen 12-15 L/min via non-rebreather mask for 15-20 min (works in ~70-80%; very well tolerated — no smoking or open flame near the oxygen, caution in CO2-retaining COPD); Triptan — sumatriptan 6 mg SC (most effective formulation) or 20 mg intranasal, zolmitriptan 5-10 mg nasal — faster routes preferred…
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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.