Migraine or tension-type headache?

One question separates them better than any other: does routine physical activity make it worse? Migraine is aggravated by movement. Tension-type headache is not.

The distinction matters because migraine responds to migraine-specific treatment and tension-type headache largely does not. A great many headaches labeled “tension” are in fact mild migraine, and 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 verbatim: at least two of bilateral location, pressing/tightening quality, mild or moderate intensity, and no aggravation by routine activity — plus no nausea or vomiting, and no more than one of photophobia or phonophobia.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 discriminator.

When the label is wrong

If a “tension headache” ever forces you into a dark room, or comes with nausea, or stops you doing something you wanted to do, it was never a tension-type headache. Mild migraine is routinely misfiled this way, particularly in people who have never had a severe attack and so have nothing to compare it against.

The other frequent impostor is cervicogenic headache — pain referred from the neck. If your headache tracks with neck position, desk posture, or an old neck injury, that is the thread to pull. A diagnostic occipital nerve block can settle it, because a block that abolishes the pain tells you where it was coming from.

The rebound trap

Because tension-type headache is mild enough to treat with whatever is in the cupboard, it is the headache most likely to end in medication-overuse headache. ICHD-3 sets the thresholds precisely: simple analgesics on 15 or more days a month, or triptans, ergots, opioids or combination analgesics on 10 or more days a month, sustained for more than three months, in someone who already has a headache disorder.³

Cross that line and you get a daily headache that looks like worsening tension-type headache and is in fact the treatment. It is common, it is reversible, and it is the first thing to address — see headache prevention.

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, and the work is establishing which. Where there is genuine occipital or cervical involvement, an occipital nerve block is both treatment and diagnostic test, placed under ultrasound guidance so that a negative result is trustworthy.

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. Nor does a stress trigger 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, because medication overuse changes everything downstream. See headache prevention.

Does neck and shoulder tightness mean it’s tension-type?

Not necessarily. Neck symptoms are extremely common in migraine, and pain arising from the upper cervical joints is cervicogenic headache, a third diagnosis with its own treatment.

Will Botox help my tension headaches?

Botox is approved and evidenced for chronic migraine, not for tension-type headache. If you have been offered it for tension headache, the diagnosis is worth revisiting first — see Botox for chronic migraine.

Sources

1. Headache Classification Committee of the International Headache Society. ICHD-3, 2. Tension-type headache. ichd-3.org
2. Headache Classification Committee of the International Headache Society. ICHD-3, 1.1 Migraine without aura. ichd-3.org
3. Headache Classification Committee of the International Headache Society. ICHD-3, 8.2 Medication-overuse headache. ichd-3.org