Migraine or Tension Headache? You Need Two Weeks, Not One

Most people asking this question turn out to have both, and that is the useful place to start rather than a technicality to mention at the end.

Having migraine does not protect you from ordinary headaches. Someone with eight migraine days a month usually also has a handful of dull, both-sided, get-on-with-it headaches, and the two get averaged together into a single impression of “my head hurts a lot”. A clinician will ask for the two counts separately, because they route to different decisions.

So the question is not really which one you have. It is which one this was, recorded enough times that the proportions become visible.

The two definitions, as things to record

Both disorders are defined in the International Classification of Headache Disorders, and both entries are public.

Migraine without aura asks for attacks lasting four to seventy-two hours untreated, at least two of four headache characteristics — one-sided, pulsating, moderate or severe, worsened by or causing avoidance of routine physical activity — and at least one associated feature, being either nausea and vomiting, or photophobia and phonophobia together.

Tension-type headache is close to the photographic negative of that. Episodes lasting thirty minutes to seven days, at least two of: both sides, pressing or tightening rather than pulsating, mild or moderate intensity, and not aggravated by routine physical activity. Plus both of: no nausea or vomiting, and no more than one of photophobia or phonophobia.

Notice that the second definition is largely a list of absences. That is why the distinction is easier to record than to feel — you are noting what did not happen as much as what did.

The six fields

Turn the above into six things you can mark in fifteen seconds, per headache, rather than adjectives to recognise yourself in.

1. Which side. One side, both sides, or it moved. Swapping sides between episodes is normal and worth writing down rather than smoothing over.
2. Does it pulsate? Beating with your heartbeat, worse when you bend to pick something off the floor. Yes or no.
3. How bad, in two bands. Mild-to-moderate, or moderate-to-severe. Two bands rather than a ten-point scale, because the criteria use bands and a ten-point scale drifts over months.
4. Do stairs make it worse? This is the one almost nobody volunteers and it does real work in both definitions. If you avoid routine movement because it worsens the pain, mark it.
5. Nausea. Yes or no, however mild.
6. Light and sound. Both, together, to the point of intolerance. “I need it dark” on its own is half an answer, and sound is the half that goes missing.

Two weeks of that produces something no amount of describing one bad afternoon can. Three months is better, and it is what any diary meant to hold up later needs anyway.

Why one headache cannot settle it

Both entries are written in terms of repeated episodes rather than single events. The tension-type criteria require a history of at least ten episodes before the label applies at all.

That is not bureaucratic caution. A single headache can land on either pattern by accident: a migraine attack caught early and treated can present as mild, both-sided and unremarkable, and a bad tension-type headache on a day with a hangover and no lunch can arrive with nausea attached. The pattern across episodes is the signal, and any individual one is noise.

There is a second reason, less obvious. What you notice about a headache depends heavily on what you were doing while you had it. Nobody discovers that stairs make it worse on a day they never climbed any.

The trap of the mild migraine

The most common misclassification runs one way: migraine attacks recorded as tension headaches because they were not severe.

Intensity is one of four characteristics and only two are needed. An attack that is one-sided and pulsating meets the count without ever becoming severe, and people routinely file those as “just a normal headache” because the word migraine has come to mean the bad ones. Over a year that quietly understates the migraine-day count, which is the number treatment decisions are made against.

Recording the six fields rather than a label is what protects against this. You are not diagnosing anything — you are writing down what happened, and letting somebody qualified read the pattern.

What to do with the answer

Take both counts, not a conclusion. “Fourteen headache days last month, nine of which were one-sided and pulsating with nausea, five of which were dull and both-sided” is a sentence a clinician can act on, and it is more useful than any label you could arrive at yourself.

The distinction matters practically, because the two respond to different things and because frequent use of acute medication for either can itself change the pattern over months — which is worth knowing before you treat fourteen days a month with anything, and is covered in medication overuse headache: how many days is too many.

For getting the description across in the room, how to describe migraine pain to a doctor covers the same features from the other end: what to say, in what order, so it does diagnostic work rather than conveying that it hurt.

Nothing here is a diagnosis and none of it should be treated as one. Classification is a judgement made by someone who can see your full history, and there are dozens of headache disorders beyond these two. If your headaches have changed in character, come on suddenly and severely, or arrive with new neurological symptoms, that needs a doctor rather than a fortnight of recording.

The free printable diary has a checkbox row for the six fields on its attack sheet, and Migraine Journal records the same set in about a minute, then keeps the two day-counts separately — which is the form the question actually gets asked in.