One question separates migraine from tension-type headache better than any other. Does routine physical activity make it worse? Movement makes migraine worse. It does not make tension-type headache worse.
The difference matters because migraine responds to migraine-specific treatment. Tension-type headache largely does not. A great many headaches labeled “tension” are in fact mild migraine. The wrong label leads to years of the wrong drug.
The two profiles side by side
Tension-type headache
- Both sides of the head
- Pressing or tightening quality — a band around the head, a weight on top of it — not pulsating
- Mild to moderate intensity; most people carry on working
- Not aggravated by walking or climbing stairs
- No nausea. Light or sound sensitivity may occur, but not both
Those five points are the ICHD-3 criteria almost word for word. You need at least two of four features. These are bilateral (both-sided) location, a pressing/tightening quality, mild or moderate intensity, and no aggravation by routine activity. You also need no nausea or vomiting, and no more than one of photophobia (light sensitivity) or phonophobia (sound sensitivity).1
Migraine
- Often but not always one-sided
- Pulsating rather than pressing
- Moderate to severe — enough to interfere
- Made worse by routine physical activity, which is why people keep still
- Nausea, or sensitivity to both light and sound
- Lasts 4 to 72 hours untreated
Migraine requires at least two of the first four and at least one of the last two.2 Note how the activity question appears on both lists with opposite answers. That is not a coincidence. It is the cleanest single way to tell them apart.
When the label is wrong
Does a “tension headache” ever force you into a dark room, or come with nausea, or stop you doing something you wanted to do? Then it was never a tension-type headache. Mild migraine is routinely misfiled this way. This happens especially in people who have never had a severe attack, so they have nothing to compare it against.
The other frequent impostor is cervicogenic headache — pain referred from the neck. Does your headache track with neck position, desk posture, or an old neck injury? Then that is the thread to pull. A diagnostic occipital nerve block can settle it. That is because a block that abolishes the pain tells you where it was coming from.
The rebound trap
Tension-type headache is mild enough to treat with whatever is in the cupboard. Because of that, it is the headache most likely to end in medication-overuse headache. ICHD-3 sets the thresholds precisely. The line is simple analgesics (plain painkillers) on 15 or more days a month. Or it is triptans, ergots, opioids or combination analgesics on 10 or more days a month. Either must last more than three months, in someone who already has a headache disorder.3
Cross that line and you get a daily headache. It looks like worsening tension-type headache, but it is in fact the treatment. It is common, it is reversible, and it is the first thing to address — see medication-overuse headache.
What we do for it
Frequent or chronic tension-type headache is usually not an infusion problem. It is a diagnosis problem, a rebound problem, or a neck problem. The work is finding out which. Sometimes there is real occipital (back of the head) or cervical (neck) involvement. Then an occipital nerve block is both treatment and diagnostic test. It is placed under ultrasound guidance, so a negative result can be trusted.
If the real diagnosis turns out to be migraine, the plan changes entirely — see migraine treatment.
Common questions
Can stress cause tension-type headache?
Stress is a common trigger. But tension-type headache is not simply “a headache from being stressed” and it is not psychological. And a stress trigger does not make a headache tension-type rather than migraine — stress triggers migraine too. See tension-type headache treatment.
I have headaches most days. Which is it?
Frequency alone does not decide it — both chronic migraine and chronic tension-type headache exist. What matters first is how often you are treating. That is because medication overuse changes everything downstream. See medication-overuse headache.
Does neck and shoulder tightness mean it’s tension-type?
Not necessarily. Neck symptoms are extremely common in migraine. And pain that comes from the upper cervical (neck) joints is cervicogenic headache. That is a third diagnosis with its own treatment.
Will Botox help my tension headaches?
Botox is approved and backed by evidence for chronic migraine, not for tension-type headache. Were you offered it for tension headache? Then the diagnosis is worth a second look first — see Botox for chronic migraine.
Migraine and tension-type headache can live in the same person, so treatment follows the pattern rather than the label. See tension-type headache treatment or migraine care in St. Louis for how each is handled.
Sources
- Headache Classification Committee of the International Headache Society. ICHD-3, 2. Tension-type headache. ichd-3.org
- Headache Classification Committee of the International Headache Society. ICHD-3, 1.1 Migraine without aura. ichd-3.org
- Headache Classification Committee of the International Headache Society. ICHD-3, 8.2 Medication-overuse headache. ichd-3.org