Tension headache: what it is, and when it is actually migraine

A tension headache is a pressing or tightening pain on both sides of the head, often described as a tight band around it. It is usually mild to moderate, does not come with nausea and does not get worse when you move. It is the most common type of headache, but many people who think they have tension headaches actually have migraine.

A tension headache can still be unpleasant enough to disrupt your day. Below you can read what it is, how it differs from migraine, and when it makes sense to look further.

What is a tension headache?

A tension headache (doctors call it tension-type headache) is a headache with a pressing or tight feeling on both sides of the head. Unlike migraine, the pain is usually mild to moderate and does not come with nausea or sensitivity to light and sound.

It is often called a stress headache, but despite the name there is no scientific evidence that it is caused by psychological stress. The word "tension" describes the tight feeling, not mental tension. A better name might be "tight headache".

Many people have an occasional tension headache. It is usually not serious and goes away on its own. A small number of people have it on 15 or more days a month, which is called chronic tension-type headache.

Which symptom is most indicative of a tension headache?

The most typical sign is a pressing, tight pain on both sides of the head, like a band. Other features:

• mild to moderate pain: unpleasant, but usually not disabling
• no nausea or vomiting: this sets it apart from migraine
• no worsening with activity: with migraine, moving around makes the pain worse
• lasts hours to days: sometimes several days in a row

Not everyone experiences these symptoms in the same way. Headache is individual.

What triggers tension headaches?

To be honest, doctors still know little about the exact cause. People often link tension headaches to stress, tiredness, poor sleep, missed meals or long hours at a screen, but there is no firm evidence that any of these cause it. There is also no evidence that tight, painful muscles around the skull are the cause. Treatments aimed at relaxing muscles, such as botox or physiotherapy, have little scientific support for tension-type headache.

That makes tension headache frustrating: it is very common, yet poorly understood. What we do know is that a careful diagnosis matters, because the biggest pitfall is missing a diagnosis of migraine.

Tension headache or migraine: what is the difference?

This is where things often go wrong. Many people who believe they have tension headaches actually have migraine, and the difference matters, because migraine can be treated effectively.

• Type of pain: tension headache is pressing and tight, on both sides; migraine is throbbing or pounding, often on one side.
• Intensity: tension headache is mild to moderate; migraine is moderate to severe.
• Nausea: not with tension headache; common with migraine.
• Sensitivity to light and sound: rare with tension headache; common with migraine.
• Worse with movement: no with tension headache; yes with migraine.
• Treatment options: limited for tension headache; extensive for migraine.

What can be mistaken for tension headache?

Migraine is the condition most often mistaken for tension headache, especially milder attacks or attacks that start with neck pain. About 10 million people in the UK live with migraine, and many of them do not know it, because they think they simply get "ordinary headaches". The World Health Organization lists migraine among the most disabling conditions in the world. Taking painkillers on many days can also cause a headache of its own (medication overuse headache), which can feel similar.

How to prevent tension headaches?

There is no proven way to prevent tension headaches, because the cause is not well understood. Some people find that regular sleep, regular meals, drinking enough water, regular movement and breaks from the screen help. If you find yourself taking painkillers on many days, talk to your GP, as frequent use can make headaches worse. And if your headaches keep coming back, it is worth checking whether they are really migraine.

When should you look further?

If your headache is severe, keeps coming back, or comes with nausea or sensitivity to light, it is probably not a tension headache. It may be migraine, and effective treatments exist: triptans and the gepants atogepant and rimegepant to treat attacks, and the gepants and the monoclonal CGRP inhibitors erenumab, fremanezumab and galcanezumab to prevent them.

Many people with migraine wait years before they get the care they need. Your GP can assess your headaches, and the NHS website has general information about headache types.

When to get urgent help

Call 999 or go to A&E if you have:

• a sudden, severe headache that reaches its worst within seconds or minutes
• weakness or numbness on one side of your body or face
• slurred speech or difficulty understanding words
• loss of vision that does not come back
• a first ever aura after the age of 50
• a headache with a high temperature and a stiff neck

If you are worried but it is not an emergency, call NHS 111.

Is it migraine? Find out

At The Migraine Clinic, a migraine specialist can help you get the right diagnosis. Consultations are fully online by video, and you do not need a referral.

• Take the free migraine test.
• Read what migraine is.
• See how to start.

This article was written by the medical team of The Migraine Clinic.