How can I differentiate between migraine and other types of headache in a primary care setting?

To differentiate migraine from other types of headache in primary care, focus on the characteristic features of the headache:

• Location: Migraine pain is typically unilateral but can be bilateral, whereas tension-type headache is usually bilateral and cluster headache is unilateral around the eye or side of the head/face.
• Pain quality: Migraine pain is pulsating (throbbing or banging), tension-type headache is pressing or tightening (non-pulsating), and cluster headache pain can be sharp, burning, or throbbing.
• Intensity: Migraine pain is moderate to severe, tension-type headache is mild to moderate, and cluster headache is severe to very severe.
• Effect on activities: Migraine is aggravated by or causes avoidance of routine activities, tension-type headache is not aggravated by routine activities, and cluster headache is associated with restlessness or agitation.
• Associated symptoms: Migraine often includes nausea, vomiting, and sensitivity to light and sound, and may have aura symptoms such as visual disturbances, sensory changes, or speech disturbance that develop gradually over 5 to 60 minutes and are fully reversible. Tension-type headache usually has no associated symptoms, and cluster headache presents with autonomic symptoms on the same side as the headache (e.g., red/watery eye, nasal congestion, eyelid swelling).
• Duration: Migraine attacks last 4 to 72 hours in adults, tension-type headaches can last from 30 minutes to continuous, and cluster headaches last 15 to 180 minutes.

Use a headache diary to record frequency, duration, severity, associated symptoms, medication use, and possible triggers over at least 8 weeks to aid diagnosis.

Be alert for red flags or atypical features that may require further investigation or referral.

This approach allows differentiation of migraine from tension-type and cluster headaches in primary care and supports appropriate management decisions.

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