Migraine or tension headache: how to tell the difference

All the headaches are not all the same. Putting a name to the type of headache changes the support and the effectiveness of treatment [1]. This article explains how to distinguish between the three most common types— tension headache, migraine and Horton's headache — what migraine auras are, and the warning signs Good to know for quick reference.

On this page

• Tension headache
• Migraine
• The migraine aura
• Horton's headache (cluster headache)
• Warning Signs
• The Pitfall of Pain Medications
• Keep a headache diary
• Myths and misconceptions
• Frequently asked questions
• Sources

Tension headache

Visit tension headache is the more common. Most adults experience this at one time or another, and it does not indicate a serious illness [1].

How it manifests itself

• Dull pain, as a headband or a helmet
• Bilateral, felt on both sides of the head
• Intensity mild to moderate
• No worsening during normal physical activity
• No nausea no significant symptoms or vomiting
• Sensitivity muscle tenderness upon palpation of the nape of the neck, temples, and scalp
• Duration : from 30 minutes to several days
• Possibility of a mild intolerance to light or noise (never both at the same time in the typical form)

Common Triggers

• Stress and emotional tension
• Posture prolonged (computer work, driving)
• Fatigue and lack of sleep
• Dehydration
• Jumps meals, hypoglycemia
• Tensions Tight neck muscles and trapezius muscles
• Bruxism (teeth grinding) and jaw tension
• Anxiety and mood disorders

What to Do

• Identifier and address the triggers
• Improve posture and taking regular breaks
• Stay Hydrated, eat at regular times, get enough sleep
• Exercise Regular exercise (documented preventive effect)
• Stretching neck and shoulders
• Pain relievers in over-the-counter (acetaminophen, ibuprofen) for acute pain; use sparingly
• Seek medical advice if frequent headaches (more than 15 days per month) or worsening

To remember

• Visit tension headache is the most common, usually bilateral, and does not worsen with exertion [1]
• Visit migraine is more intense, one-sided, and throbbing, often accompanied by nausea and sensitivity to light and noise
• Visit Horton's headache is rare but extremely intense, occurs on one side around the eye, and comes in bursts
• The’migraine aura is a transient neurological symptom that precedes a migraine in approximately 25 % of people [2]
• Visit warning signs (thunderclap headache, neurological deficits, fever, recent trauma) require prompt medical attention
• A Headache Diary facilitates diagnosis and treatment adjustment
• Visit excessive use The use of pain relievers can perpetuate and worsen headaches (medication-overuse headache)

Migraine

Visit migraine affects approximately 12 % of adults [3], with a predominance of women plain and simple. It’s a neurological disorder, not just a «bad headache.».

How it manifests itself

• Pulsating pain, which beats in time with the heart
• Unilateral most often (but may be bilateral in some cases)
• Intensity moderate to severe
• Worsened through physical exertion, even mild
• Often accompanied by nausea, sometimes vomiting
• Photophobia and phonophobia (sensitivity to light and noise)
• Sometimes osmophobia (sensitivity to odors)
• Duration : 4 to 72 hours without treatment
• Often followed by a recovery phase (fatigue, a «hangover-like» feeling without having had alcohol)

Common Triggers

• Hormonal fluctuations (menstrual cycle, contraception, perimenopause)
• Stress and stress relief («weekend migraine»)
• Missing or oversleeping
• Skipping Meals, dehydration
• Certain foods depending on the person (chocolate, aged cheeses, red wine, MSG)
• Alcohol, especially red wine
• Variations weather-related (atmospheric pressure)
• Lights intense light, screens, noisy environments
• Strong Odors (fragrances, chemicals)

Available treatments

• Crisis Interventions : NSAIDs, acetaminophen, triptans (sumatriptan, rizatriptan, etc.), antiemetics, newer gepants
• Background Treatments To consider if there are more than 4 attacks per month or if the attacks are severe: beta-blockers, anticonvulsants, tricyclic antidepressants, CGRP inhibitors
• Non-pharmacological approaches : regular sleep patterns, stress management, regular physical activity, identifying and avoiding triggers
• Therapies Additional treatments that may be helpful: biofeedback, relaxation, acupuncture, magnesium, vitamin B2

The migraine aura

Environment 25 % among people with migraines have a will have : transient neurological symptoms (15 to 60 minutes) preceding the headache [2].

The Most Common Symptoms

• Shimmering spots of light (scintillating scotomas), often in the center of the visual field
• Zigzag lines that are gradually expanding
• Blurred Vision or temporary loss of part of the visual field
• Sometimes tingling in one hand, extending up toward the arm and face
• Speech Disorders transient (trouble finding the right word, difficulty articulating)
• Rarely, vertigo or weakness on one side
• Symptoms are changing last a few minutes and disappear in less than an hour

What You Need to Know

• The’will have is not dangerous in and of itself
• She precedes usually accompanied by a headache, but may occur without a headache in some people
• A first aura, especially after age 40, warrants a medical evaluation
• A change If the symptoms present in the usual way (longer duration, greater intensity, new symptoms), medical advice is also required
• The’will have may resemble a stroke: if the person has never had an aura, or if the symptoms are atypical, it is necessary to dial 911 without hesitation
• Visit migraine with aura is associated with a slightly increased cardiovascular risk and should be included in the overall assessment (smoking, hormonal contraception, high blood pressure)

Horton's headache (cluster headache)

Visit Horton's headache is much more rare, but recognizable. It is one of the most painful headaches that exist, sometimes called « suicide headache »because of its intensity [1].".

How it manifests itself

• Extremely intense pain, unilateral
• Located around or behind the eye, sometimes radiating to the temple or jaw
• Short-term crises : 15 minutes to 3 hours
• Occurring in salvos over several weeks, sometimes several times a day
• Watery Eyes, redness of the eye, runny nose on the side where the pain is felt
• Sometimes fall eyelid, constriction of the pupil
• Agitation during the attack (the person can’t sit still, unlike with a migraine, when one seeks quiet and darkness)
• Often triggered at night, at a relatively fixed time

Specific Treatments

• High-flow oxygen as a mask (often very effective in just a few minutes)
• Injectable triptans or as a nasal spray to stop an attack
• Background Treatments such as verapamil to reduce the frequency of bursts
• Sometimes corticosteroids short-term to interrupt a period of crises
• The suspension of the tobacco and alcohol is recommended during times of crisis
• Tracking neurological often useful

Comparison Chart of the Three Types

Characteristic	Tension	Migraine	Horton
Location	Double-sided, banner-style	Often unilateral	Unilateral, around the eye
Type of pain	Deaf, under pressure	Pulsatile	Very intense, like a stab in the heart
Intensity	Mild to moderate	Moderate to severe	Extreme
Duration	30 minutes to several days	4 to 72 hours	15 minutes to 3 hours, in bursts
Nausea	Rare	Frequent	Rare
Light / Noise	Rare	Common	Rare
Behavior	Variable	Calm, rest	Agitation
Ocular signs	Absent	Aura Possible	Watery eyes, redness, runny nose

Warning Signs

Some signs should encourage quickly look up or to go to the emergency room, because they may indicate a serious underlying condition (cerebral hemorrhage, infection, intracranial hypertension, or other) [1][4].

When to seek help quickly

• Headache « a bolt from the blue »appearing within a few seconds, at maximum intensity right from the start"
• First Severe headaches after age 50
• Headache worsening gradually over several weeks
• Neurological symptoms associated symptoms: weakness, speech difficulties, vision loss, confusion, loss of consciousness
• Fever, stiff neck, rash (suspected meningitis)
• Headache after a head injury, especially if it gets worse
• Headache in a patient immunocompromised or who have cancer
• Headache from the pregnant woman, especially on the 3rd^e quarter
• Headache with severe vomiting, without a prior diagnosis
• Headache caused by the position, physical exertion, coughing, sneezing, sexual intercourse

Where to Go in Case of an Emergency

• In the presence of a acute warning sign, call 911 or go to the hospital emergency room
• For a Severe headache but no warning signs, a prompt medical consultation (the same day or in the coming days) is appropriate
• In Quebec, the front doors include the emergency room, the First-Line Access Desk (GAP), a walk-in clinic, and 811 (option 1, Info-Santé)
• Never trivialize an unusual headache in someone who doesn't usually get them

Do you have frequent or unusual headaches? Omicron Clinic offers a medical evaluation of headaches, the Prescribing acute and maintenance treatments, and referrals to neurology as needed, at our locations in Quebec, with the option of a teleconsultation for the initial consultation. Make an appointment or opt for the teleconsultation.

The Pitfall of Pain Medications

A overuse The use of painkillers can, paradoxically, perpetuate and worsen headaches: this is the medication-overuse headache [1].

How She Settles In

• Usage regular simple pain relievers (acetaminophen, ibuprofen) for more than 15 days a month
• Or use of triptans, opioids, combination medications for more than 10 days a month
• On several consecutive months
• Headache becomes a daily occurrence or almost every day
• The’stop The medication may cause a temporary worsening of symptoms before improvement sets in

How to Prevent and Treat It

• Limit the use of pain relievers for fewer than 10 to 15 days per month
• Hold a log of catches to accurately assess the frequency
• If headaches become frequent, make an appointment to discuss long-term treatment
• Visit Treatment of Headaches Caused by Substance Abuse is based on gradual, guided weaning, sometimes with specific support
• Often followed by a improvement complete resolution of the pain after a few weeks to months

Keep a headache diary

Visit Headache Diary is a simple tool which speeds up diagnosis and treatment adjustments. Several mobile apps make this easier.

Points to Note

• Date and the time the headache began
• Duration total
• Intensity on a scale of 0 to 10
• Location (unilateral or bilateral, frontal, occipital)
• Type pain (throbbing, dull, stabbing)
• Symptoms associated symptoms (nausea, photophobia, aura, watery eyes)
• Triggers possible factors (diet, sleep, stress, menstrual cycle, weather, alcohol)
• Medicines taken (name, dose, time)
• Efficiency of the treatment
• Impact on daily activities (absences from work, canceled plans)

What is it used for?

• Clarify diagnosis (often more useful than imaging tests)
• Identifier personal triggers
• Measure the actual frequency of seizures
• Evaluate the effectiveness of crisis interventions
• Decide the benefits of long-term treatment
• Detect possible drug abuse
• Facilitate consultations with the doctor and a referral to a neurologist if necessary

Myths and misconceptions

«A migraine is just a really bad headache.»

False. Migraine is a neurological disorder with its own specific mechanisms. It requires specific treatment, using acute and preventive medications that differ from common pain relievers. Treating migraine as a simple headache often leads to inadequate treatment and delayed diagnosis.

«You should get an imaging test for any headache.»

False. The vast majority of headaches (tension headaches, migraines) do not require imaging. A clinical examination and patient history are sufficient to make a diagnosis. Imaging is reserved for cases with warning signs, atypical presentation, or unusual progression.

«Triptans are only for severe cases.»

False. Triptans are medications specifically designed to treat migraines and are recommended when simple pain relievers are not enough. They are most effective when taken early in the attack. Their use is regulated, but they are not reserved for extreme cases.

«If I have migraines, it must be for life.»

Not necessarily. Migraines change over time. Many people find that their attacks decrease or disappear after menopause, particularly migraines related to hormonal cycles. Modern preventive treatments often significantly improve quality of life.

«A headache is always caused by a vision problem.»

Often false. Inappropriate vision correction can cause tension headaches, especially toward the end of the day. However, most primary headaches (tension, migraine, cluster) are not related to vision. An optometric exam is helpful when in doubt, but it alone does not explain chronic headaches.

Frequently asked questions

How many times a month is too many?

Starting at 4 migraine attacks per month, long-term treatment is generally discussed. For tension headaches, experiencing headaches on more than 15 days per month indicates a chronic condition that warrants evaluation and a structured treatment plan. Any headache that significantly impairs quality of life or leads to very frequent use of pain relievers should prompt a medical consultation.

How can you tell the difference between a migraine aura and a stroke?

A migraine aura usually develops over several minutes, consists of progressive visual symptoms, and resolves within an hour, followed by a headache. A stroke, on the other hand, is characterized by a sudden, immediate onset of symptoms (weakness, paralysis, speech difficulties), without any gradual onset. If in doubt—especially if this is your first aura or if the symptoms are different from usual—call 911 immediately.

Is the birth control pill safe for people with migraines?

Estrogen-progestin contraception is generally not recommended for women with migraine with aura, due to an increased cardiovascular risk. Progestin-only contraceptives (birth control pills, hormonal IUDs, implants) are often a better option. A personalized discussion with your doctor can help you assess the risks and benefits.

Can children get migraines?

Yes, and it’s common. Migraines in children and adolescents may be shorter in duration than those in adults and are sometimes accompanied by abdominal pain, vomiting, or dizziness. A medical evaluation helps distinguish migraines from other causes and determine an age-appropriate treatment.

When should you have a brain imaging test?

Imaging is indicated in the presence of a warning sign (thunderclap headache, first severe headache after age 50, progressive worsening, neurological deficit, fever, trauma, or immunosuppression), an atypical presentation, or a marked change in a previously recognized headache pattern. It is not warranted for a stable, typical migraine.

Are there headache specialists in Quebec?

Yes. Neurologists—and more specifically, certain headache specialists—treat complex cases. Patients are usually referred by a family doctor or a specialized nurse practitioner. The initial consultation with a primary care physician often allows for the diagnosis and treatment to begin, and for a referral to a neurologist if necessary.

Sources

1. International Headache Society. International Classification of Headache Disorders (ICHD-3).
2. Canadian Headache Society. Recommendations for the Diagnosis and Treatment of Migraines and Headaches.
3. Migraine Canada. Information on Migraines, Treatments, and Resources for Patients.
4. Collège des médecins du Québec. Clinical Guides and Guidelines.
5. INESSS — National Institute for Excellence in Health and Social Services. Guides and Reviews on Headache Management.
6. Heart & Stroke Canada. Recognizing the Signs of a Stroke (VITE Acronym).
7. American Headache Society. Guidelines on the Treatment of Migraine and Headache Disorders.

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