Migraine vs Tension Headache: How to Tell Them Apart

Migraine and tension-type headache are both diagnosed from the pattern of the attacks, using published criteria instead of a laboratory result. The criteria are short, and they are public. The International Classification of Headache Disorders, third edition, sets out what each diagnosis requires. Read both side by side and most of the confusion turns out to be about two things the criteria already anticipate: how ordinary it is to have both, and that sometimes the honest answer is neither.

What ICHD-3 requires for migraine

The headline description of migraine without aura is compact. ICHD-3 calls it a recurrent headache disorder manifesting in attacks lasting 4 to 72 hours, with typical characteristics of unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia.

Those criteria turn the description into a checklist with thresholds. A diagnosis needs at least five attacks. Each lasts 4 to 72 hours untreated or unsuccessfully treated. The headache has at least two of four characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, and aggravation by or causing avoidance of routine physical activity such as walking or climbing stairs. During the headache there is at least one of nausea and/or vomiting, or photophobia and phonophobia. And a fifth criterion closes the set: the headache is not better accounted for by another ICHD-3 diagnosis.

Two of those five carry more weight than they look. The five attack minimum is not decoration. ICHD-3 states that individuals who otherwise meet the criteria but have had fewer than five attacks should be coded as probable migraine without aura, so two convincing episodes are a strong suspicion and not yet a diagnosis. And the last criterion, the one about another diagnosis accounting for the headache better, is the whole reason this is a clinical framework instead of a quiz. It asks whether the headache is the illness or a symptom of something else, and that is not a question a checklist answers.

What ICHD-3 requires for tension-type headache

Tension-type headache is described as episodes of headache, typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting minutes to days. The pain does not worsen with routine physical activity and is not associated with nausea, although photophobia or phonophobia may be present.

Its criteria mirror the shape of migraine's and invert the content. Episodes last from 30 minutes to 7 days. At least two of four characteristics must be present: bilateral location, pressing or tightening non-pulsating quality, mild or moderate intensity, and not aggravated by routine physical activity such as walking or climbing stairs. Then both of two conditions must hold: no nausea or vomiting, and no more than one of photophobia or phonophobia. And here too a final criterion closes the set, that the headache is not better accounted for by another ICHD-3 diagnosis. Both sets end on the same sentence, and it is the most consequential one in either.

One note on where that wording comes from. Those are the criteria for infrequent episodic tension-type headache, and the frequent episodic form shares criteria B to D with it exactly. The chronic form does not, and we come to how it differs further down.

That last criterion is where the two diagnoses part company most sharply. Migraine requires the presence of associated symptoms. Tension-type headache requires their near absence. Almost everything else can overlap.

The five features that do the work

Location comes first, and it is the feature people over-trust. Unilateral location is listed among the typical characteristics of migraine, and bilateral location among those of tension-type headache, but neither is a rule. Migraine needs only two of its four characteristics, so a bilateral migraine is entirely possible. ICHD-3 adds that migraine headache in children and adolescents under 18 is more often bilateral than in adults, with unilateral pain usually emerging in late adolescence or early adult life, and that migraine headache is usually frontotemporal.

Quality is next. Pulsating for migraine, pressing or tightening and explicitly non-pulsating for tension-type headache. People tend to describe the second as a band, a vice or a weight, and the first as something that keeps time with a pulse.

Intensity separates the two by band rather than by point. Migraine is moderate or severe. Tension-type headache is mild or moderate. Moderate belongs to both, which is exactly why a moderate headache is the hardest one to classify from the outside.

Physical activity is the one criterion with a behavioural answer instead of a descriptive one. Migraine is aggravated by, or causes avoidance of, routine physical activity such as walking or climbing stairs. Tension-type headache is not aggravated by it. Whether you took the stairs is a fact you can still recall a week later.

Associated symptoms are where the two sets diverge instead of overlapping. Migraine needs at least one of nausea and/or vomiting, or the pair of photophobia and phonophobia. Tension-type headache requires no nausea or vomiting and no more than one of photophobia or phonophobia. Consistent nausea has already moved you across the line the criteria draw.

There is one physical sign on the tension-type side, and it is found in a clinic rather than at home. Increased pericranial tenderness is, in ICHD-3's words, the most significant abnormal finding in patients with any type of tension-type headache: typically present between headaches, exacerbated during actual headache, and increasing with the intensity and frequency of headaches. A clinician finds it by palpating the muscles of the head and neck.

Frequency changes the label, not the feeling

Both disorders are subdivided by how often they occur, and the cut points are where people get lost. Infrequent episodic tension-type headache means at least 10 episodes on fewer than 1 day a month on average, under 12 days a year. Frequent episodic tension-type headache means at least 10 episodes on 1 to 14 days a month on average for more than 3 months. Chronic tension-type headache means headache on 15 or more days a month on average for more than 3 months, at least 180 days a year.

Chronic tension-type headache is also described differently, not just more often. ICHD-3 calls it a disorder evolving from frequent episodic tension-type headache, with daily or very frequent episodes lasting hours to days or unremitting, where the pain still does not worsen with routine physical activity but may be associated with mild nausea, photophobia or phonophobia. Its criterion is tighter than that description sounds. Chronic tension-type headache allows no more than one of photophobia, phonophobia or mild nausea, and allows neither moderate or severe nausea nor vomiting. Moderate nausea does not fit it, so the rule shifts shape at the chronic end instead of simply relaxing.

Fifteen days is also the chronic migraine threshold, which sets up a collision the classification resolves explicitly. Both chronic tension-type headache and chronic migraine require headache on 15 or more days a month. For chronic tension-type headache the headache must meet tension-type criteria on at least 15 days; for chronic migraine it must meet migraine criteria on at least eight.

ICHD-3 gives the worked example: someone with headache on 25 days a month, meeting migraine criteria on eight days and tension-type criteria on 17, fulfils both sets of criteria, and in those cases only the diagnosis of chronic migraine should be given.

The same precedence appears from the other direction. Because tension-type-like headache is within the diagnostic criteria for chronic migraine, that diagnosis excludes the diagnosis of tension-type headache or its types. We covered what the 15 day threshold means in more detail in how many migraines a month is normal.

Self-diagnosis is unreliable, and the sources say so plainly

ICHD-3 does not pretend this is easy even for clinicians. The diagnostic difficulty most often encountered among the primary headache disorders, it states, is in discriminating between tension-type headache and mild forms of migraine without aura, and this is more so because patients with frequent headaches often suffer from both disorders.

Sharper evidence of how far self-labelling drifts comes from a study of a different label entirely. Schreiber and colleagues, publishing in the Archives of Internal Medicine in 2004, screened 2,991 patients who had a history of self-described or physician-diagnosed sinus headache, no previous diagnosis of migraine and no evidence of infection. Of those, 88% were found at the screening visit to have migraine-type headache: 80% fulfilled migraine criteria and a further 8% fulfilled migrainous criteria.

Screening tools narrow the odds without settling anything. The ID Migraine validation study, published in Neurology in 2003, tested nine questions in 563 primary care patients reporting headaches in the previous 3 months. A three-item subset covering disability, nausea and sensitivity to light performed best, with sensitivity of 0.81, specificity of 0.75 and a positive predictive value of 0.93. Useful odds. Not a diagnosis. The same paper observed that migraine remains substantially undiagnosed in primary care.

Having both is the expected case

Tension-type headache is very common, with a lifetime prevalence in the general population ranging in different studies between 30% and 78%. ICHD-3 notes that the infrequent episodic form occurs in almost the entire population and usually has very little impact on the individual, which is why the classification separates it out rather than labelling nearly everyone as having a headache disorder.

Coexistence is normal rather than contradictory. Frequent episodic tension-type headache often coexists with migraine without aura, ICHD-3 says, and both disorders need to be identified, preferably through use of a diagnostic headache diary, because the treatments of each differ considerably. It adds that patients need to learn to distinguish between the two headache types if they are to select the right treatment for each while avoiding medication overuse.

That warning is not incidental. Among people with medication-overuse headache who had a previous primary headache diagnosis, ICHD-3 notes, most have migraine or tension-type headache or both. Treating years of migraine as ordinary tension headaches, with whatever is in the cupboard, is one quiet route to a medication day count nobody planned.

Tension-type headache is also not the psychological consolation prize it is sometimes treated as. ICHD-3 records that while it was previously considered to be primarily psychogenic, a number of studies since the first edition strongly suggest a neurobiological basis, at least for its more severe subtypes. And chronic tension-type headache, in the classification's own words, is a serious disease, causing greatly decreased quality of life and high disability.

When the answer is neither, and when it cannot wait

Everything above assumes the headache is a primary headache disorder, meaning the headache is the illness instead of a symptom of something else. Testing that assumption is exactly what the last criterion in each set is for, and it is why the SNNOOP10 review of red flags, published in Neurology in 2019, opens by noting that a minority of headache patients have a secondary headache disorder. A minority is not nobody, and no amount of comparing location against quality will find one.

A few of those presentations need care immediately. A headache of sudden or abrupt onset is what headache medicine calls a thunderclap headache, defined in ICHD-3 as reaching maximum intensity in under 1 minute, and the SNNOOP10 authors describe it as associated with serious intracranial disorders of vascular origin, in particular subarachnoid hemorrhage. One prospective study they cite identified subarachnoid haemorrhage in 25% of 148 episodes of thunderclap headache. On neurological signs the same paper is blunt: neurologic deficits should always raise serious concern regardless if a headache is present or not.

The American Migraine Foundation gives the instruction in plain words. It advises that if you experience any of these symptoms during what otherwise seems like a migraine attack, you should go to the hospital immediately; that on thunderclap headache, if you are experiencing this type of headache pain for the first time, you should visit the ED, meaning the emergency department; and that you should also visit the ED right away if you experience any new and sudden-onset neurological symptoms, including weakness on one side of the face or body, numbness, the inability to speak normally, vision changes, unusual dizziness, or trouble walking. If that is what is happening now, stop reading and get emergency help. This page is not worth the delay, and nothing on it changes that answer.

The rest of the SNNOOP10 list is appointment material, not emergency material, and the shape of it is worth knowing. It enumerates red flags including systemic symptoms such as fever, neoplasm history, neurologic deficit including decreased consciousness, sudden or abrupt onset, older age with onset after 65 years, pattern change or recent onset of new headache, positional headache, headache precipitated by sneezing, coughing or exercise, papilledema, progressive headache and atypical presentations, pregnancy or puerperium, painful eye with autonomic features, posttraumatic onset of headache, pathology of the immune system such as HIV, and painkiller overuse or a new drug at onset of headache. Any of those belongs in front of a clinician instead of in a side by side comparison, and a first severe or genuinely new headache later in life is worth showing someone whatever the exact age cue says.

None of this is a reason to be frightened of an ordinary headache. It is a reason to treat which of the two is it as a question with a third possible answer, and to notice that the third answer is the only one with a clock on it.

What to write down so the difference shows

You do not have to diagnose yourself, and after the section above it should be clear why you cannot. What you can do is record the five things the criteria ask about, on the day it happens: where the pain sat, what it felt like, how bad it was, whether ordinary movement made it worse, and whether nausea or light and sound sensitivity came with it. Duration belongs there too, since 30 minutes and 30 hours point in different directions.

Some tracking apps are built around that list. MigrAid, for example, uses a 16-zone head map for location instead of a free-text box, which keeps the unilateral question answerable months later when the details have faded. Our guide to tracking migraine triggers covers the rest of the record, and if an appointment is coming, we have a separate piece on preparing for a neurologist visit.

Bring the raw entries rather than your conclusions. A clinician can classify a month of specific days quickly. Nobody can do anything with the sentence that you get bad headaches sometimes.

The bottom line

Migraine typically runs unilateral, pulsating, moderate to severe, worsened by routine activity, and it arrives with nausea or with light and sound sensitivity. Tension-type headache typically runs bilateral, pressing, mild to moderate, unbothered by movement, and it arrives with almost none of that. Two of four features on either side, plus the associated-symptom rule, is the part you can observe for yourself. It is not the whole test. The criteria also set a minimum number of attacks on the migraine side, a duration range on both, an episode count on the tension-type side, and they both end by requiring that no other diagnosis better accounts for the headache, which is the part that needs a clinician.

The honest caveat is the one ICHD-3 puts first. The hardest headache to classify is a moderate one, and people with frequent headaches often have both disorders at once. A day-by-day record of those five features is what turns a guess into something a clinician can work with in ten minutes. And if a headache ever arrives at full force in under a minute, or brings new neurological symptoms with it, none of this applies and emergency care does.