Migraine vs Tension Headache: How to Tell the Difference

Migraine and tension-type headache are distinct diagnoses with different biology, different triggers, and very different treatments — and the most reliable way to tell them apart is by symptom pattern, not pain intensity. Migraine is a neurological disease characterized by attacks that are typically one-sided, pulsating or throbbing, moderate to severe in intensity, worsened by routine physical activity, and accompanied by nausea, light sensitivity, or sound sensitivity. Tension-type headache is bilateral, pressing or tightening in quality, usually mild to moderate, not aggravated by movement, and without nausea. Getting the diagnosis right is not academic: triptans and CGRP-targeted therapies that can stop a migraine in its tracks do nothing for a tension headache, and the over-the-counter analgesics that manage tension pain are often ineffective for migraine. Treating the wrong headache with the wrong drug is one of the most common reasons people spend years suffering when effective options are available.

This guide draws on peer-reviewed research from three headache specialists in the Convene network. Peter Goadsby, MD at Ronald Reagan UCLA Medical Center, co-authored the International Classification of Headache Disorders that defines the diagnostic criteria used worldwide [1]. Richard Lipton, MD at the Montefiore Headache Center has produced the most widely cited epidemiology and treatment burden data in the field [3][4][5]. David Borsook, MD PHD, Professor Emeritus at Harvard Medical School and director of the Pain and Imaging Neuroscience Group at Boston Children's Hospital, has synthesized how migraine engages neural systems that tension-type simply does not [6].

Why the distinction matters

Headache is one of the most prevalent symptoms in medicine, but lumping all headaches together leads to poor care. Tension-type headache is more common — affecting around 38% of people at some point in their lives — while migraine affects approximately 12% of the U.S. population [3]. Despite being less prevalent, migraine is responsible for far more disability. Lipton's large-scale epidemiology work consistently shows that migraine is the second leading cause of years lived with disability globally, with a disproportionate burden on working-age adults [5]. Tension-type, while uncomfortable, rarely prevents people from functioning.

That difference in disability traces directly to a difference in mechanism. Migraine is not a more severe version of a tension headache. It is a biologically distinct disease that engages specific brain circuits in ways that tension-type does not. The treatments that target those circuits work for migraine and are irrelevant for tension-type. This is why correctly identifying which type you have determines not just which pill to reach for during an attack, but whether prevention is appropriate and what kind.

The ICHD diagnostic criteria

The International Classification of Headache Disorders (ICHD), which Goadsby helped develop, is the definitive international reference for headache diagnosis [1]. The criteria define two conditions precisely, which makes it possible to diagnose reliably in clinical practice.

Migraine without aura requires all of the following:

• At least five lifetime attacks that fit the criteria
• Each attack lasts 4 to 72 hours (untreated or unsuccessfully treated)
• At least two of these pain characteristics: unilateral location, pulsating quality, moderate or severe intensity, aggravated by or causing avoidance of routine physical activity
• During the attack, at least one of: nausea or vomiting, or both photophobia (light sensitivity) and phonophobia (sound sensitivity)
• Not better explained by another diagnosis

Tension-type headache criteria:

• At least ten lifetime episodes fitting the criteria
• Each attack lasts 30 minutes to 7 days
• At least two of these pain characteristics: bilateral location, pressing or tightening quality (non-pulsating), mild to moderate intensity, not aggravated by routine physical activity
• Both of the following: no nausea or vomiting, and no more than one of photophobia or phonophobia (not both)

The most practically useful distinguishing features are the location (one-sided versus both-sided), the quality (throbbing versus squeezing), and the presence of nausea or the combination of light and sound sensitivity. If you have all three of the migraine markers — one side, throbbing, nausea or light-and-sound sensitivity — you almost certainly have migraine. If your headache is bilateral, squeezing, and you can still function normally, it is almost certainly tension-type.

At a glance

The pathophysiology difference

The reason these headaches feel different comes down to the neural systems involved. Goadsby's comprehensive 2017 pathophysiology review in Physiological Reviews describes migraine as fundamentally a disorder of sensory processing — the brain of a person with migraine loses control over its sensory inputs in a way that is genetically predisposed and environmentally triggered [2]. At the core of a migraine attack is activation of the trigeminovascular system: the trigeminal nerve sends signals from pain-sensing fibers around blood vessels in the meninges, releasing calcitonin gene-related peptide (CGRP) and other signaling molecules. This cascade produces the throbbing pain and, critically, also causes central sensitization — a state in which the spinal cord and brain become hypersensitive, explaining why even light touch on the scalp becomes painful during a severe migraine and why light and sound feel unbearable.

Borsook's 2015 synthesis in the Journal of Neuroscience adds another layer: migraine involves changes in cortical excitability, autonomic dysfunction, and what he describes as an allostatic load model — the migraine brain is not just reacting to a trigger but is chronically operating closer to a threshold that ordinary brain activity can push across [6]. This framework explains phenomena like allodynia (pain from normally non-painful stimuli), the prodrome of yawning and mood changes that precedes pain, and why sleep deprivation, skipped meals, or hormonal shifts reliably provoke attacks.

Tension-type headache does not engage these systems. It does not involve trigeminovascular activation, CGRP release, or central sensitization in the same way. The pain in tension-type likely arises from peripheral sensitization of pericranial muscles — the muscles of the scalp, neck, and jaw — without the cascading central amplification that defines migraine. This mechanistic difference is precisely why triptans (serotonin agonists that work on the trigeminal system) relieve migraine but have no effect on tension-type headache. You cannot treat a muscle-tension problem with a drug designed for a neurological cascade.

When it can be hard to tell

The ICHD criteria are cleaner on paper than in a doctor's office. Several real-world patterns make differentiation harder:

Bilateral migraine. Approximately 40% of migraines present with bilateral pain, particularly as an attack evolves. Bilateral location alone should not rule out migraine if nausea, light-and-sound sensitivity, or activity worsening are present.

Overlap and mixed headache disorder. Some people have both migraine and tension-type. When tension headaches are frequent, they can lower the threshold for migraine attacks, and the two can become entangled. This is called mixed or combined headache disorder and often requires careful diary-based diagnosis over several weeks.

Medication overuse headache. Taking acute headache medications on more than 10 to 15 days per month can cause a daily or near-daily headache that has features of both tension and migraine and responds poorly to either treatment. Recognizing this pattern is critical because the fix is not a better drug — it is stopping the overused one.

Red flags that require immediate evaluation. A sudden headache that reaches maximum intensity within seconds (thunderclap headache), a headache with fever and neck stiffness, new headache after age 50, or headache associated with neurological symptoms like weakness, vision loss, or confusion are not migraine or tension-type until proven otherwise. These require emergency evaluation.

What effective treatment looks like for each

For migraine:

Acute (attack) treatment: Triptans (sumatriptan, rizatriptan, and others) are first-line for moderate-to-severe attacks in most patients [4]. Over-the-counter options like ibuprofen and aspirin plus caffeine (Excedrin Migraine) can work for mild attacks. CGRP receptor antagonists (gepants) are a newer option that work differently from triptans and are useful when triptans fail or cause side effects.

Prevention: For patients with four or more migraine days per month, or attacks severe enough to significantly impair function, preventive therapy reduces frequency and severity. Options include CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab), the oral gepant atogepant, and older options like topiramate, propranolol, and amitriptyline.

For tension-type:

Acute treatment: NSAIDs (ibuprofen, naproxen) and acetaminophen are the mainstays. Caffeine can enhance their effectiveness. Aspirin, ketoprofen, and diclofenac are also effective.

Prevention: For frequent tension-type headache (more than 15 days per month), low-dose amitriptyline has the strongest evidence. Stress management, biofeedback, and physical therapy targeting pericranial muscles are useful non-drug options.

For both: Medication overuse is a shared risk. Acute medications — whether triptans, NSAIDs, or acetaminophen — should not be taken more than 10 to 15 days per month. Exceeding that threshold often worsens both conditions and can convert episodic headache into chronic daily headache.

When to see a neurologist

Consider a neurology referral if:

• You are having four or more headache days per month and have never been evaluated for migraine specifically
• Over-the-counter pain relievers are no longer controlling your headaches, or you are using them more than two days a week
• You have tried two or three acute treatments and none have worked consistently
• You have had to miss work, school, or family obligations because of headaches in the past six months
• You experience aura symptoms — visual disturbances, tingling, or speech changes — before a headache

Headache specialists have access to preventive treatments, diagnostic tools, and a nuanced understanding of mixed headache presentations that general practitioners often cannot provide in a standard appointment. For people with frequent or severe headaches, the difference between good and poor care is often access to that specialist knowledge.

Questions to ask your doctor

• Based on my symptoms, do you think my headaches are migraine, tension-type, or a mix of both?
• Am I a candidate for preventive treatment, and if so, where do we start?
• How do I track my headaches to tell whether treatment is working?
• Am I at risk for medication overuse headache based on how often I take pain relievers?
• If my current treatment stops working, what are the next options — and is there a headache specialist I should see?

The bottom line

Migraine and tension-type headache have distinct diagnostic features, distinct biology, and distinct treatments. Migraine is a neurological disease with specific criteria — unilateral or pulsating pain, nausea, light-and-sound sensitivity, worsening with movement — while tension-type is bilateral, squeezing, and non-disabling. If you have been treating all your headaches the same way and not getting consistent relief, it is likely that a more precise diagnosis would change what you are using. A headache specialist can make that distinction and match you to a treatment that fits how your brain actually works.