Differentiating tension-type headache and migraine: integrating cognitive deficits, psychological distress, and pain perception for diagnostic precision

Tension-type headache (TTH) and migraine share overlapping clinical features, which can complicate differential diagnosis. This study examined differences in pain characteristics, psychological distress, and cognitive performance between individuals with TTH and migraine and evaluated whether these features could help distinguish the two groups. A total of 103 adults, including 51 individuals with TTH and 52 with migraine, were assessed. Participants completed a two-week headache diary, the Depression Anxiety Stress Scales-21 (DASS-21), and computerized 2-back, go/no-go, and dot-probe tasks. Five machine-learning models were evaluated using nested cross-validation, combining leave-one-out validation with five-fold hyperparameter tuning. Compared with TTH, migraine was associated with greater pain intensity and higher levels of depression, anxiety, and stress. Participants with TTH showed better working-memory and inhibitory-control performance, whereas attentional bias did not differ significantly between groups. Machine-learning models achieved accuracies ranging from 0.884 to 0.922 and AUC values from 0.943 to 0.959. These findings suggest that combining pain-related, psychological, and cognitive measures may provide complementary information for distinguishing TTH from migraine and may contribute to more accurate diagnostic assessment.