Headache Types: Cervicogenic vs Tension vs Migraine vs Temporal Arteritis
Referred Pain Patterns · 9 min read · 2025-12-06
Introduction
Headache is one of the most common presentations in clinical practice. Four types demand confident differentiation: cervicogenic headache (arising from the cervical spine), tension-type headache, migraine, and temporal arteritis (the one you must never miss).
Tension-Type Headache
The most common primary headache. Prevalence exceeds 70% lifetime.
Character: Bilateral, pressing or tightening ("band-like"). Mild to moderate intensity.
Duration: 30 minutes to 7 days. Can become chronic (>15 days/month).
Features: No nausea or vomiting. No photophobia AND phonophobia together (one may be present). Not aggravated by routine physical activity. No aura.
Associations: Stress, poor sleep, jaw clenching, eye strain.
Migraine
Affects approximately 15% of the population. More common in women (3:1).
Character: Unilateral (60%), pulsating/throbbing. Moderate to severe intensity.
Duration: 4–72 hours if untreated.
Features: Nausea and/or vomiting. Photophobia AND phonophobia. Aggravated by physical activity. May be preceded by aura (visual — scintillating scotoma, fortification spectra; sensory — unilateral tingling).
Associations: Hormonal changes, certain foods, sleep disruption, weather changes. Strong family history.
Cervicogenic Headache
A secondary headache arising from structures in the upper cervical spine (C1–C3 segments).
Character: Unilateral, starting in the neck/occiput and radiating to the forehead, temple, or around the eye. Non-throbbing.
Duration: Variable, often fluctuating.
Features: Triggered or worsened by neck movements or sustained postures. Reduced cervical range of motion. Tenderness over upper cervical joints and suboccipital muscles. Same side consistently affected. No aura.
Key differentiation from migraine: Cervicogenic headache is always provoked by neck movement or palpation. Migraine is not.
Test: Manual pressure over the C1–C2 and C2–C3 facet joints reproduces the headache pattern.
Temporal (Giant Cell) Arteritis
This is the one you cannot miss. An inflammatory vasculitis of medium and large arteries, predominantly the temporal artery.
Age: Almost exclusively >50 years old (peak 70–80).
Character: New-onset headache in an older adult. Temporal region, often unilateral. May be mild or severe.
Red flags:
- New headache in a patient over 50
- Jaw claudication (pain with chewing) — most specific symptom
- Visual disturbance — amaurosis fugax, diplopia, or sudden vision loss
- Scalp tenderness (painful to brush hair or rest head on pillow)
- Temporal artery abnormality — tender, thickened, non-pulsatile
- Systemic symptoms — fever, weight loss, fatigue, polymyalgia rheumatica
- Markedly elevated ESR (often >50mm/hr) and CRP
Urgency: Untreated temporal arteritis can cause permanent bilateral blindness. If suspected, start high-dose corticosteroids immediately — before biopsy confirmation.
Comparison
Clinical Pearl
The single most important question in headache assessment: "Is this a new headache in a patient over 50?" If yes, temporal arteritis must be excluded before any other diagnosis is considered. Check ESR and CRP urgently.
Summary
Bilateral + band-like + no nausea = tension. Unilateral + throbbing + nausea + aura = migraine. Unilateral from neck + provoked by movement = cervicogenic. New headache in >50 + jaw claudication + visual symptoms = temporal arteritis — treat immediately.