Migraine vs tension-type headache: how to tell them apart

The most reliable way to tell the two apart is to look at the whole attack rather than the pain alone. A migraine is a set of symptoms: a throbbing headache that can be severe and disabling, often on one side, worse on moving, with feeling or being sick and sensitivity to light and sound. A tension-type headache is usually a milder, pressing or tightening ache on both sides that you can usually carry on through, with few or no other symptoms.

In real life the picture is not always so tidy. Milder migraines can look like tension headaches, and the two can occur in the same person. That is why a pattern recorded over weeks, and a conversation with a GP, are more useful than a single episode.

The Migraine Trust sets out the main differences in a table. The table below follows its description and adds the ICHD-based definition given in NICE Clinical Knowledge Summaries.

The NHS describes migraine as a condition that causes a set of symptoms known as a migraine attack. The main symptoms are a throbbing headache that can be severe, often on one side and worse with moving around, feeling or being sick, and being very sensitive to light and sounds. Early symptoms can include tiredness and yawning, food cravings, mood changes, a stiff neck and passing urine more often. Some people get an aura, such as zigzag lines, flashing lights, tingling or difficulty speaking, which the NHS says should not last longer than 1 hour.

The Migraine Trust says up to 1 in 3 people with migraine also get aura, that attacks tend to happen in stages and that around 10 million people in the UK have the condition. Triggers vary and can include stress, skipping meals, hormonal changes and changes in sleep.

NICE CKS describes tension-type headache as the most common primary headache disorder, meaning it is not caused by another underlying condition. It typically presents as recurrent episodes of headache lasting from 30 minutes to 7 days without nausea or vomiting, with at least two of the following: both sides, a pressing or tightening non-pulsating quality, mild or moderate intensity, and no worsening with routine physical activity such as walking or climbing stairs.

CKS classifies it by frequency. Infrequent episodic means less than 1 day of headache a month. Frequent episodic means at least 10 episodes on fewer than 15 days a month for more than 3 months. Chronic means 15 days or more a month for more than 3 months. Frequent episodic and chronic tension-type headache can have a significant impact on quality of life at work, home and school.

Neither condition is diagnosed with a scan or blood test. The Migraine Trust says keeping a headache diary can help in making a diagnosis, and the NHS describes keeping a diary of headaches to work out triggers. A neurological examination should be normal in tension-type headache, according to NICE CKS.

For migraine, the NHS lists painkillers such as ibuprofen and paracetamol, triptans and gepants, and medicines for sickness, with preventive options including beta blockers, antidepressants and epilepsy medicines, acupuncture, relaxation, CBT and vitamin B2. For episodic tension-type headache, NICE CKS advises reassurance and simple over-the-counter pain relief such as paracetamol, aspirin or an NSAID, and avoiding opioids. For frequent or chronic forms it mentions acupuncture, physiotherapy, regular exercise, CBT, relaxation and a trial of amitriptyline.

Both pages warn about medication overuse. The NHS says to try not to take painkillers for more than 2 days a week for migraine because this can cause more headaches, and CKS advises avoiding frequent and excessive use of acute analgesia for tension-type headache.

The NHS says to call 999 if a headache comes on suddenly and is extremely painful, or comes with problems speaking or remembering, loss of vision or blurred or double vision, drowsiness or confusion, a seizure, a very high temperature with meningitis symptoms, weakness on one side, or a recent head injury. It advises an urgent GP appointment or NHS 111 for headache triggered or made worse by coughing, sneezing, bending down or exercise, headache with vomiting, or headache with jaw pain when eating or a sore, tender scalp. A new pattern of headache is always worth discussing with a GP.