Tension-type headache or migraine: how to tell the difference and what helps

Headache is one of the most common health complaints in the world. According to the Global Burden of Disease study, tension-type headache and migraine are among the most frequent diseases, and migraine is one of the main causes of disability in young adults, especially women (Stovner et al., 2018).

But not all headaches are the same. Knowing whether it is a tension-type headache or a migraine changes what helps, what to avoid and when to see a doctor.

How to tell the difference

Doctors use the International Classification of Headache Disorders (ICHD-3) to diagnose the types of headache (Headache Classification Committee of the International Headache Society, 2018). In plain language, the main differences are these:

Tension-type headache

• A tight or pressing pain, like “a band around the head” or a weight.
• Generally on both sides: forehead, temples, nape.
• Mild to moderate intensity: it bothers you, but lets you carry on with your day.
• It does not get worse on climbing stairs or walking.
• No nausea or vomiting. There may be some sensitivity to light or to noise, but not to both.
• Lasts from 30 minutes to several days.
• Often associated with tension in the neck and shoulders, stress, tiredness and poor sleep quality.

Migraine

• Throbbing or pulsating pain.
• Often on one side, although it can be on both or switch sides.
• Moderate to severe intensity: it hinders or prevents activities.
• Gets worse with routine physical activity.
• It comes with nausea or vomiting, or sensitivity to light and noise: the person seeks a dark, quiet room.
• Lasts 4 to 72 hours, without treatment.
• About a third of people with migraine have aura: temporary neurological symptoms, usually visual (flickering lights, zigzag lines, blind spots), sometimes tingling, which appear before or during the pain and last up to an hour.
• It is more common in women and may be related to the menstrual cycle.

Side by side

And when it looks like both?

It is common. Many people with migraine also have episodes of tension-type headache, and migraine can start with neck pain. Muscle tension in the neck also appears in many migraine attacks. A headache diary (date, duration, intensity, symptoms, medication, possible triggers) kept for a month or two is a great help to the doctor in making the diagnosis.

Common triggers

Some factors can trigger or aggravate both forms. Knowing them helps prevent them:

• Stress and, curiously, the relief after stress (weekend migraine).
• Sleep that is insufficient, irregular or excessive.
• Skipping meals and dehydration.
• Caffeine: in excess or its absence, when you are used to it.
• Alcohol, especially red wine in some people with migraine.
• Hormonal variations, such as menstruation.
• Sensory stimuli: bright light, screens, strong smells, noise.
• Tension in the neck and shoulders, sustained posture and a clenched jaw, more associated with tension-type headache. See Working seated: neck, shoulder and back pain and what to do and Clenched jaw and tight teeth: causes, signs and what helps.

Triggers vary greatly from person to person. The headache diary is the best way to identify yours. Avoiding every possible trigger is neither realistic nor necessary: the aim is to reduce the ones that weigh most.

Beware of overusing painkillers

This is a little-known and very important point. Taking medication for headaches too often can make the headaches more frequent, creating a cycle that is hard to break. It is called medication-overuse headache.

According to international criteria, overuse is defined as lasting more than three months in people who have a headache on 15 or more days a month:

• Simple painkillers (such as paracetamol or anti-inflammatories) on 15 or more days a month.
• Migraine-specific medicines, opioids or combination painkillers on 10 or more days a month.

If you recognise yourself in this, do not stop the medication abruptly on your own: speak to your family doctor or neurologist, who can guide you in reducing it and propose preventive treatment. A diary that also records the medication taken is essential.

What helps

Habits that make a difference

• Regular sleep, with similar times every day, including at weekends.
• Regular meals and good hydration.
• Moderate, steady caffeine, without peaks or sudden cuts.
• Regular aerobic exercise. In a trial with people with migraine, 40 minutes of exercise three times a week reduced the frequency of attacks to a similar extent as relaxation and a preventive medicine (Varkey et al., 2011).
• Stress management: relaxation, breathing, mindfulness, cognitive behavioural therapy in selected cases.
• Breaks and movement for those who work at a computer, and exercises for the neck and shoulders.

Medical treatment

For attacks, there are simple painkillers and migraine-specific medicines, which should be used with guidance and within the limits above. When headaches are frequent or disabling, the doctor may propose preventive treatment. There are now several effective options for migraine, so it is worth seeking help rather than suffering on.

Massage: what the evidence says

Massage of the neck, shoulders, scalp and face is sought by many people with headaches. The evidence is encouraging, but limited:

• Migraine: in a controlled trial, weekly massage for five weeks reduced the frequency of attacks and improved sleep quality, compared with a group with no intervention (Lawler and Cameron, 2006). It was a small study.
• Tension-type headache: in a trial of 56 people, massage directed at the tension points of the head and neck reduced the frequency of headaches. But a placebo treatment also reduced it, with no significant difference between the two (Moraska et al., 2015). Massage improved the perception of relief more.
• Systematic reviews suggest that manual therapies may help with chronic primary headaches, but the studies have important methodological limitations (Chaibi and Russell, 2014).

In summary: massage can relieve the associated muscle tension, reduce stress and give relief, especially in tension-type headache and between migraine attacks. It should be seen as a complement to habits and medical treatment, not an alternative.

During a migraine attack, most people prefer rest in a dark, quiet room. Massage is generally not indicated at that moment, because touch and movement can be bothersome. It is more useful in the periods between attacks.

Relief at home

• Cold on the forehead or nape (in migraine) or heat on the neck and shoulders (in tension-type headache), whichever you find works better.
• Gentle self-massage of the temples, base of the skull and shoulders.
• Rest in a calm environment, hydration.

Warning signs

The great majority of headaches are primary (not caused by another disease). But some signs require prompt medical assessment (Do et al., 2019).

Call 112 if you have:

• A sudden and very severe headache, which reaches its peak within seconds or a few minutes (“the worst pain of my life”).
• Headache with fever and a stiff neck, skin spots, confusion or drowsiness.
• Weakness, numbness, drooping of one side of the mouth, difficulty speaking or loss of vision, especially if it is the first time or different from your usual aura.
• Headache after a head injury.
• Seizures or fainting.

See a doctor soon if:

For any questions, call SNS 24 (808 24 24 24).

At Luxmed Clinic

At Luxmed Clinic, in Algés, massages for those who suffer from tension-type headaches focus on the neck, shoulders, scalp and face. Before the session, we ask about the type of headache and about warning signs, and recommend medical assessment whenever necessary. Massages are carried out by a massage therapist.

Massage is a wellbeing complement and does not replace medical diagnosis or treatment. Results vary from person to person.

Frequently asked questions