Migraine vs tension headache: the markers that actually tell them apart

If you have a headache right now and you’re trying to figure out which kind it is, here’s the short answer: a migraine is one-sided, pulsing, made worse by movement, and comes with nausea or light sensitivity. A tension headache is two-sided, steady pressure (“like a band around my head”), not worsened by movement, and has no nausea. If walking up a flight of stairs makes the pain worse, it’s a migraine. If you can keep working through it, it’s probably a tension headache.

That’s the 30-second answer. The rest of this post is the diagnostic detail — the markers neurologists actually use, the ones the International Classification of Headache Disorders (ICHD-3) writes down, and the ones I’ve confirmed against ~400 of my own logged attacks.

I’ve had migraines since I was a teenager. I also get tension headaches. I built Migra partly because I couldn’t reliably tell them apart in the moment, and the difference matters — they respond to completely different treatment.

The comparison table

This is the cheat sheet. Save it.

Attribute	Migraine	Tension Headache
Location	Usually one side of the head	Both sides, often forehead or back of head
Quality of pain	Throbbing, pulsing, pounding	Steady pressure, tight band, dull ache
Intensity	Moderate to severe (5–10/10)	Mild to moderate (2–6/10)
Duration	4–72 hours untreated	30 min to a few hours; rarely >24 hours
Movement effect	Gets worse with routine activity	Unchanged by movement
Nausea / vomiting	Common (~70% of attacks)	Absent
Light sensitivity	Common (photophobia)	Mild or absent
Sound sensitivity	Common (phonophobia)	Mild or absent
Aura (visual/sensory)	~25% of migraineurs experience it	Never
Trigger sensitivity	Strong (weather, hormones, sleep, food)	Mostly stress, posture, eye strain
Response to triptans	Usually yes	No (triptans don’t work)
Response to OTC painkillers	Sometimes, if taken early	Usually yes

If you scored mostly in the left column, you’re describing a migraine. Mostly right column, tension. The mixed cases are where it gets interesting — and where most misdiagnosis happens.

Location: one side vs both sides

The single most-reliable marker in the table is unilateral vs bilateral pain.

About 60% of migraine attacks are one-sided. Even when they spread, they usually start on one side, and the dominant pain stays asymmetric. The medical term is hemicrania — literally “half-head” — which is where the word “migraine” comes from (Greek hēmikrania, ἡμικρανία → Latin hemicrania → Old French migraigne → migraine).

Tension headaches are almost always bilateral. The classic description: a band of pressure around the forehead, a vise on both temples, or a dull ache at the base of the skull spreading up both sides. Patients describe it as “wearing a tight hat.”

Where this gets tricky: about 40% of migraines are not one-sided. So a bilateral headache doesn’t rule migraine out — it just shifts the probability. You need the other markers to confirm.

Quality: throbbing vs pressure

The second-most-reliable marker is the quality of the pain.

Migraines pulse. They throb. They feel like your heartbeat is in your head. If you’ve ever put your hand on your temple during an attack and felt the rhythm of the pain match your pulse — that’s the trigeminovascular system activating: neurogenic inflammation, CGRP release, and altered cranial blood flow. The exact mechanism is still debated, but the rhythmic quality is the most reproducible diagnostic clue. It’s why your headache gets worse when you stand up (gravity), worse when you exercise (heart rate up), and worse when you bend over (intracranial pressure up).

Tension headaches are steady. Constant pressure. They don’t pulse. They don’t change with your heartbeat. If you describe your headache as “a vise” or “a band,” that’s tension. If you describe it as “a hammer” or “throbbing” — migraine.

A common mistake people make: assuming severity equals migraine. It doesn’t. A mild throbbing pain is still migraine-typical. A severe but steady pressure can still be tension. Quality matters more than intensity.

Duration: hours vs days

Untreated migraines last 4 to 72 hours. That’s not a typo — three full days is the upper bound of a single untreated attack. Most fall in the 8–24 hour range.

Tension headaches typically resolve in 30 minutes to a few hours. The chronic variant (chronic tension-type headache, CTTH) can persist longer, but the episode intensity stays mild-to-moderate and never crosses into the “I need to lie down in a dark room” territory.

If your headache routinely makes you cancel plans for a full day, duration alone makes migraine more likely. Tension headaches don’t usually disable you for a day.

Response to triggers

Migraine triggers are well-documented and reproducible:

• Weather changes — especially barometric pressure drops, often 6–10 hPa within 24 hours
• Hormonal shifts — estrogen withdrawal around menstruation is a trigger for 50–60% of women with migraine
• Sleep changes — both too little and too much (a sleep-in Saturday is a classic Saturday-morning migraine setup)
• Food — aged cheese, red wine, processed meats (nitrates), MSG, aspartame for some
• Skipping meals — glucose drops are a strong trigger
• Stress letdown — migraines often hit on day 1 of vacation, not during the stressful week

Tension headache triggers are narrower:

• Sustained posture — slouching at a desk, looking down at a phone
• Eye strain — long screen sessions, uncorrected vision problems
• Stress and emotional tension — yes, the name is honest, but only for tension headaches; for migraines, stress is one of dozens of triggers
• Dehydration — though this triggers migraines too

If your headaches correlate strongly with weather, hormones, or specific foods, that’s a migraine pattern. If they only happen on long workdays at the computer, that’s a tension pattern.

Neurological symptoms: aura, photophobia, nausea

This is the cleanest diagnostic line. Tension headaches do not produce neurological symptoms. Migraines do.

Aura is the most distinctive. About 25% of migraineurs experience it — visual zigzags, blind spots, shimmering lines, occasionally sensory tingling or speech difficulty. It lasts 5–60 minutes, usually precedes the headache, and is fully reversible. Aura without headache exists (silent migraine), but aura does not occur with tension-type headache (it’s exclusion criterion B in ICHD-3). If you’ve had aura, you have migraine. Full stop.

Photophobia (light sensitivity) — squinting at normal indoor lighting, needing to draw the curtains, finding sunlight unbearable — is a migraine marker.

Phonophobia (sound sensitivity) — needing the room quiet, finding normal conversation grating — same.

Osmophobia (smell sensitivity) — perfumes, cooking smells, gasoline becoming intolerable — also migraine.

Nausea and vomiting are present in ~70% of migraine attacks. Almost never in tension headaches.

The ICHD-3 criteria for migraine require at least one of: nausea/vomiting, OR (photophobia AND phonophobia). If a headache hits the location/quality/duration criteria but has none of these neurological features, it doesn’t meet ICHD-3 migraine criteria — it falls into “probable migraine” or “tension-type headache.”

When migraine gets misdiagnosed as tension (and vice versa)

The misdiagnosis problem is real. The Schreiber & Lipton 2004 sinus headache study found that 88% of patients with a history of self-reported or physician-diagnosed “sinus” headache actually met diagnostic criteria for migraine. A meaningful slice of “tension headaches” are also probable migraines — particularly bilateral migraines without dramatic aura.

The reverse happens too. Severe tension headaches occasionally get treated as migraines, but this is less common because triptans (the migraine-specific abortive class) simply don’t work on tension headaches — so the misdiagnosis self-corrects when treatment fails.

The common failure modes:

1. Bilateral migraine misread as tension. Because the textbook description says migraines are one-sided. They often aren’t.
2. Mild migraine misread as “just a headache.” Severity isn’t a diagnostic criterion. Mild throbbing one-sided pain with light sensitivity is still a migraine.
3. Prodrome misread as tension. What feels like morning neck tension can be the prodrome phase of an attack that will fully bloom by afternoon.
4. Sinus migraine misread as sinus infection. Migraine activates the trigeminal nerve, which innervates the sinuses. You get facial pressure, nasal congestion, watery eyes — without any infection. Antibiotics do nothing. Triptans work.

The “does it respond to a triptan?” test is the most practical at-home diagnostic, though you need a prescription. If sumatriptan stops your headache within an hour, it’s a migraine.

When to see a doctor

For both kinds of headache, there’s a threshold for medical attention. The American Migraine Foundation’s general guidance:

• More than 4 headache days a month — worth seeing a primary care doctor or neurologist
• Headaches affecting work, school, or relationships — same
• Any headache that disables you for a full day — same

And the urgent flags. Go to an emergency room or seek immediate care for:

• Sudden thunderclap headache — peaks within 60 seconds, worst headache of your life
• Headache with fever, stiff neck, rash — could be meningitis
• Headache with neurological deficits — sudden weakness, vision loss, slurred speech, confusion
• Headache that wakes you from sleep regularly
• New headache pattern after age 50 — secondary causes become more likely with age
• Headache after head trauma — even days later

These aren’t migraine or tension territory — they’re “rule out something more serious” territory.

How tracking distinguishes them

If you’ve read this far and you’re still not sure which kind you get — that’s normal. The fastest way to find out is to track every headache for 8 weeks. Patterns emerge that aren’t visible in retrospect.

What to log for each headache:

1. Location — left, right, both, where specifically
2. Quality — throbbing or steady?
3. Intensity — 1 to 10
4. Duration — start time and end time
5. Triggers in the previous 24 hours — sleep, food, weather, stress, hormones
6. Associated symptoms — nausea, light/sound sensitivity, aura
7. What you took — and whether it worked

After ~20 headaches, two clusters typically emerge:

• A “tension cluster” — bilateral, steady, low-intensity, short, triggered by workdays
• A “migraine cluster” — one-sided, throbbing, longer, with neurological features

Or you discover you only have one type. Either way, you now have data your neurologist can act on, and you can also fill out validated screening tools — the MIDAS test for disability burden and the HIT-6 test for impact severity — with real numbers instead of guesses.

This is what Migra logs for every attack — location on a head silhouette, intensity dial, throbbing-vs-steady toggle, associated symptoms checkbox, trigger autofill from weather and Apple Health data. After 30 logged attacks, the on-device AI starts surfacing your specific pattern. The point isn’t the app, though — the point is having the data. Notes app, paper journal, spreadsheet all work. The only useless approach is trusting memory; recall bias destroys headache pattern recognition.

What to do with this

If you’ve made it through and now know which kind you mostly get:

Tension headache people — focus on posture, screen breaks, hydration, magnesium supplementation, regular exercise, and stress reduction. OTC ibuprofen or naproxen works for most. Sustained tension headaches that occur 15+ days/month are “chronic tension-type headache” and warrant a neurology visit — there are preventive treatments.

Migraine people — get an abortive medication (triptan or gepant) from a doctor. OTC painkillers alone are a losing strategy long-term because they cause medication-overuse headache after ~10 days/month of use. Track your triggers. If you have 4+ migraine days a month, ask about preventive medication (propranolol, topiramate, CGRP antagonists). The migraine treatment landscape has been transformed in the last 5 years — if you haven’t seen a neurologist since 2019, you’re missing options.

Mixed people (you get both) — most people do. The work is learning to recognize which kind is starting, because the treatment diverges within the first 30 minutes. A wrong-guess can cost you a day.

Migraine and tension headache are different diseases that happen to share a body part. Once you can tell them apart in the moment, half the battle is over.