Differences between Migraine and Tension Headache

Migraine and tension headache

Migraine and tension headache (clinically termed tension-type headache or TTH) are distinct primary headache disorders. Accurate differentiation between these conditions is required for clinical management, as the pharmaceutical treatments for each often differ. The International Classification of Headache Disorders, 3rd edition (ICHD-3), establishes the diagnostic criteria used to separate the two based on pain quality, location, and associated autonomic symptoms.

While tension-type headache is the most prevalent headache disorder globally, affecting roughly 40% of the population at any given time, migraine is the leading cause of headache-related disability. Migraine affects approximately 12% of the general population and is more common in women than in men.

Comparison table

Feature	Migraine	Tension-type headache
Pain location	Usually unilateral (one side)	Bilateral (both sides)
Pain quality	Pulsating or throbbing	Pressing or tightening
Intensity	Moderate to severe	Mild to moderate
Duration	4 to 72 hours	30 minutes to 7 days
Nausea or vomiting	Common	Absent
Physical activity	Worsens the pain	Does not affect the pain
Sensitivity	Light and sound sensitivity	Rare; may have one but not both
Aura	Present in 25% of cases	Absent

Venn diagram comparing Differences between Migraine and Tension Headache

Clinical symptoms

Migraine pain is characteristically unilateral, though it may shift sides or become bilateral during an attack. The pain quality is described as pulsating or throbbing, often synchronous with the pulse. For a diagnosis of migraine without aura, patients must experience at least five attacks lasting between 4 and 72 hours when untreated. These attacks are typically accompanied by at least one of the following: nausea, vomiting, photophobia (light sensitivity), or phonophobia (sound sensitivity). Routine physical activities, such as walking or climbing stairs, aggravate the intensity of a migraine.

Tension-type headaches present as a steady, non-pulsating ache. Patients often describe the sensation as a tight band encircling the head or a heavy weight on the scalp. Unlike migraine, TTH is predominantly bilateral and is not associated with systemic symptoms like nausea. While a person with TTH may experience either photophobia or phonophobia, the presence of both symptoms excludes a TTH diagnosis under ICHD-3 guidelines. Most individuals can continue their daily activities during a TTH episode, as movement does not exacerbate the pain.

Pathophysiology

The underlying causes of these headaches involve different neurological pathways. Migraine is understood as a neurovascular disorder. It involves the activation of the trigeminovascular system, leading to the release of inflammatory neuropeptides such as calcitonin gene-related peptide (CGRP). Tension-type headache was previously thought to be caused solely by muscle tension in the neck and scalp. Modern research suggests that while peripheral muscle tenderness is a factor, central sensitization—a state where the central nervous system becomes overly sensitive to pain signals—is the primary mechanism for chronic TTH.