Migraine or tension headache, how to tell them apart

It started behind your right eye about an hour ago. The overhead light in the kitchen has become unbearable, you have gone off the idea of lunch, and every time you stand up too quickly the pain gives a distinct throb. Last week you had a headache as well, but that one felt like a tight band across your forehead all afternoon and you got on with your day.

Those are two different problems. Most people call any bad headache a migraine and dismiss anything they can work through as nothing much, but the distinction is practical. What helps a migraine attack and what helps a tension type headache are not the same, and neither are the things that bring them on.

What a migraine attack actually involves

A migraine is a neurological event, not simply severe head pain, and the pain is only one part of it. In the day beforehand some people feel yawny, irritable or unusually thirsty, and learn to read that as a warning. Some also get aura, which comes just before or with the pain and lasts minutes rather than seconds: zigzag lines, a blind spot that grows, flickering lights at the edge of vision, sometimes pins and needles up an arm.

Then the headache. Typically one sided, often throbbing, and reliably worse for moving around, climbing stairs or bending over. Nausea is common and some people are sick. Light and sound become intolerable, and what you want more than anything is a dark quiet room. An untreated attack can run from a few hours to two or three days, and many people feel wrung out for another day afterwards.

What a tension type headache feels like

Milder, on both sides, and more like pressure than pulsing. A band around the head, or a heavy ache across the forehead and temples, often with tightness at the back of the neck. It does not usually worsen when you move, it rarely comes with nausea, and most people work through it. It might last half an hour, or grumble on for days.

Real life is less tidy than that table. Plenty of people get both kinds, and some migraines affect both sides. Our page on how our doctors approach headache and migraine goes through the assessment itself. If unsteadiness troubles you as much as the pain, our article on getting dizziness assessed online is worth reading. Pain across the cheekbones and upper teeth that is worse when you lean forward points somewhere else again, and treatment for sinus infection and facial pain covers that pattern.

Triggers, and why a diary beats guesswork

Triggers are personal, and they usually add up rather than acting alone. A late night on its own does nothing. A late night plus a skipped breakfast plus a deadline produces an attack. The usual suspects are missed meals, not drinking enough, irregular sleep including weekend lie ins, red wine, a change in caffeine either way, stress and the slump after it, hormonal changes around periods, flickering light, and long stretches at a screen.

Keeping a diary sounds like homework, and it is still the most useful thing you can bring to an appointment. For a month, note:

1. The date, the time it started, and roughly how long it lasted.
2. Where the pain was and what it felt like, in your own words.
3. Anything that came with it: aura, nausea, light sensitivity, neck tightness.
4. What you took, how early you took it, and whether it helped.
5. Sleep, meals, alcohol, stress, and where you were in your cycle if that applies.

Patterns show up in writing that are invisible in memory. Most people either underestimate how many days a month they are losing, or blame entirely the wrong trigger.

The painkiller trap worth knowing about

This part is uncomfortable but honest: painkillers taken too often can start causing headaches themselves. Medication overuse headache creeps up on you. The tablets take the edge off for a few hours, the headache returns, you take more, and over months you end up with a near daily background headache that nothing touches. Painkillers containing codeine are the worst offenders, and even simple painkillers taken on most days of the week can do it.

If you are reaching for headache tablets on more days than not, raise it with a doctor rather than stopping abruptly on your own. Coming off them can make headaches worse for a week or two before they improve, which is far easier with a plan and someone to check in with.

When to get urgent help

• A headache that comes on suddenly and is the worst of your life, reaching full force within a minute.
• Headache with a fever and a stiff neck, or with a rash that does not fade when you press it.
• Any headache after a blow to the head, particularly with drowsiness, repeated vomiting or confusion.
• New weakness or numbness down one side, a drooping face, slurred speech, or a change in vision.
• Headache that is worse when you lie flat, cough, strain or bend forward, or that wakes you from sleep.
• A new type of headache starting after the age of 50, or any headache getting steadily worse over weeks.
• Tenderness in the scalp or temple, or jaw pain when chewing.

Dial 999 for a sudden severe headache that peaks almost instantly, for any sign of stroke, or for a headache with fever and a stiff neck. Use 111 for a headache that worries you but is clearly not one of those, including a pattern that has changed or pain that will not shift after several days.

How an online appointment works for headaches

Headache is worked out almost entirely from the story, which is why a conversation is the right tool and a video appointment loses very little. A UK registered doctor will ask how attacks begin, how long they last, what comes with them, how many days a month you are affected, and what you have tried. Where treatment is appropriate that might mean something to take during an attack, or a daily preventer if attacks are frequent, and the doctor can prescribe when that is clinically appropriate. A referral letter can follow if you need specialist assessment. The practical side is explained in how a Time Medics appointment runs, costs are listed on the page of consultation fees, and you can book a video appointment for a time that suits you.

Frequent headaches are rarely a one appointment problem either. Preventers need several weeks to show their worth and often need adjusting, so being able to book a review without taking time off work matters. Stress feeds straight into tension headaches, so if that is the bigger picture for you, an anxiety treatment plan reviewed monthly may be as relevant as anything aimed at your head.

Small changes that earn their place

Regular meals and a consistent bedtime, weekends included, do more for migraine frequency than most people expect, because a brain prone to migraine dislikes sudden change of any kind. Drink water through the day, and keep caffeine steady rather than swinging between four coffees and none. If you work at a screen, raise it to eye height and get up regularly, because a neck held at one angle for eight hours reliably produces a band of pressure by five o'clock.

You do not have to accept losing days to this. If your headaches are frequent, changing in character, or sending you to bed, start a consultation about your headaches, bring your diary, and work out which headache you actually have.