How to Tell What’s Really Going On
Headaches are common, but a misdiagnosis is even more common. Many people arrive at Sydney Headache & Migraine Clinic™ convinced they’re dealing with tension headaches, only to discover they’re experiencing migraine attacks (or vice versa). Because these two conditions share similar symptoms, many people end up treating the wrong problem and relying on pain medicine that offers little improvement. Some even develop medication-overuse headache without realising it.
Our role isn’t just to treat headache disorders. It’s to identify the cause of your headache pain through a structured, evidence-informed diagnostic process. This guide breaks down the differences clearly so you can understand what’s happening inside your nervous system.
Why These Conditions Get Confused
Tension headaches and migraines are two of the most common primary headache disorders worldwide. They share several features:
- Overlapping headache symptoms such as head pain, pressure, neck pain, or light and sound sensitivity.
- Similar risk factors, including emotional stress, posture strain, disrupted sleep, and hormonal fluctuations.
- Episodes lasting a few hours or longer.
In clinical practice, the overlap means many people continue treating the wrong type of headache for years. Some migraines never produce throbbing pain. Some tension headaches produce symptoms that feel more intense than expected. Some patients experience both conditions, sometimes in the same week.
This is why an accurate diagnosis matters. Without it, patients often fall into medication overuse patterns or develop transformed migraines, where the nervous system becomes increasingly sensitised.
What a Tension Type Headache Actually Feels Like
A tension-type headache usually presents as a dull ache, tightening, or pressure-like discomfort. Patients often describe it as a band around the head. Key features include:
- Bilateral pain across both sides of the head.
- Mild to moderate intensity.
- Muscle tenderness in the jaw, scalp, or shoulder muscles.
- Pain that doesn’t worsen with walking or physical activity.
- Neck tightness or neck stiffness due to muscle tension.
Common triggers include prolonged sitting, muscle tension, emotional stress, screen time, and posture-related strain. When symptoms persist, they may develop into chronic tension-type headache, which can mimic migraine and often signals underlying sensitisation in the upper cervical spine.
Learn more about Tension Type Headache.
What a Migraine Actually Involves
A migraine is a neurological disorder involving activation of the trigeminovascular system, changes in sensory processing, and altered brainstem function. Migraine headache pain is often described as throbbing pain, but not always. Aside from migraine pain, migraine symptoms may include:
- Moderate to severe pain on one side of the head (though both migraines can also be bilateral).
- Nausea, vomiting, and cognitive fog.
- Sensitivity to light, sound, or smells.
- Visual disturbances such as blurred vision or aura.
- Neck pain and stiff neck due to a sensitised brainstem.
Migraine subtypes include:
- Episodic migraine
- Chronic migraine
- Hemiplegic migraine
Common migraine triggers include hormonal fluctuations, stress, poor sleep, weather changes, and sensory overload.
Discover more about Migraine Headache Treatment
Migraine vs Tension Headache: A Practical Comparison
Pain Quality
Tension headache: Band-like pressure or dull ache.
Migraine: Pulsating, throbbing pain, often worsened by movement.
Pain Severity
Tension headache: Mild to moderate.
Migraine: Moderate to severe pain; often disabling.
Location
Tension headache: Both sides of the head.
Migraine: Usually one side, though it can vary.
Associated Symptoms
Tension headache: Muscle tenderness, neck tension, no aura or vomiting.
Migraine: Nausea, blurred vision, visual disturbances, sensitivity to light.
Duration
Tension headache: 30 minutes to 7 days.
Migraine: 4 to 72 hours.
Common Triggers
Tension headache: Stress, eye strain, posture issues, and muscle tension.
Migraine: Weather changes, hormones, sensory input, and disrupted sleep.
When a “Tension Headache” Is Actually a Migraine
Not all migraines behave like the stereotype. Some present as:
- Pressure-based headaches instead of pulsating pain.
- Neck-driven discomfort is mistaken for muscle tension.
- Light sensitivity without strong pain.
These cases frequently lead to medication overuse headache or transformed migraine. Many patients experience both migraines and tension headaches, making self-diagnosis unreliable.
The Diagnostic Process at Sydney Headache & Migraine Clinic™
At SHMC, diagnosis isn’t just about symptoms. It’s about identifying the mechanism driving your pain. Our diagnostic process includes:
- Comprehensive history and clinical interview.
- Assessment of the upper cervical spine.
- Screening for brainstem sensitisation.
- Evaluation of risk factors, triggers, and neurological patterns.
- Review of a headache diary to track frequency and other symptoms.
- Exclusion of serious neurological disorders when indicated.
This helps us distinguish between tension headache, migraine, and other primary headache disorders with accuracy grounded in modern clinical practice.
Explore our assessment approach.
Treatment Options Based on Your Actual Diagnosis
If You’re Dealing With a Tension-Type Headache
Treatment may include:
- Manual therapy focused on cervical mobility.
- Physical therapy targeting muscle activation and postural control.
- Relaxation techniques, including deep breathing.
- Ergonomic strategies to reduce mechanical load.
- Addressing emotional stress and lifestyle contributors.
If Your Headaches Are Migraines
Management involves addressing neurological sensitivity:
- Reviewing migraine triggers and pattern recognition.
- Considering acute treatment, acute medications, or abortive medications when appropriate.
- Using preventive medications (e.g., calcium channel blockers) when clinically required.
- Avoiding patterns that lead to medication overuse for headaches.
- Incorporating non-invasive options
Our approach prioritises long-term relief by addressing your underlying mechanism rather than relying on medication alone.
When to Seek Professional Help
Seek urgent assessment if you experience:
- Sudden-onset severe headache
- Sudden visual disturbances or neurological deficits
- Headache triggered by physical exertion
- Unexplained change in blood pressure accompanied by headache
- Persistent or worsening symptoms despite treatment
Identifying the Root Cause
Many patients visit us after trying multiple options without lasting improvement. Often, the missing piece is a sensitised brainstem caused by dysfunction in the upper cervical spine. When this system is triggered, it may produce:
- Migraine attacks
- Tension headaches
- Neck-driven symptoms
- Symptoms linked to both migraines and cervicogenic pathways
By identifying and treating these mechanisms directly, our clinicians deliver meaningful, lasting outcomes grounded in the latest research and SHMC’s evidence-based framework.
Tension Headache vs Migraine – FAQs
Can migraines feel like tension headaches?
Yes. Not every migraine produces classic pulsating or throbbing pain. Some migraine attacks present with pressure, tightening or a dull ache that is very similar to a tension type headache. These episodes may also come with neck pain, sensitivity to light, difficulty concentrating or other symptoms that are not immediately recognised as migraine-related. This is why self-diagnosis is often unreliable. A detailed assessment can help determine whether your headache pattern is driven by migraine mechanisms, tension-type mechanisms or a combination of both.
Why do migraines cause neck pain or stiffness?
Neck pain is a common feature of many migraine attacks. The cervical spine and the brainstem share a communication hub known as the trigeminocervical nucleus. When the brainstem becomes sensitised, normal sensory input from the neck can be interpreted as a threat, creating pain or tightness in the upper neck and shoulders. This discomfort can occur before, during or after a migraine attack. Many people assume this neck tightness is muscular, but it is often a neurological response rather than a simple mechanical strain.
Do I need scans to diagnose my headache?
Most people do not. Headache diagnosis is usually made through clinical assessment, not imaging. Scans are recommended only when symptoms suggest a structural or neurological problem that requires investigation. In most cases, a thorough examination of your medical history, headache pattern, cervical spine and potential triggers is more useful than imaging. At the Sydney Headache and Migraine Clinic, our clinicians use a structured diagnostic approach that focuses on identifying cervical involvement, brainstem sensitisation and other factors that can drive headache disorders.
Can stress trigger both migraines and tension headaches?
Yes. Stress is one of the most well-recognised triggers across both conditions. Emotional stress can cause muscle tension in the neck and shoulders, which may initiate or worsen a tension-type headache. Stress also influences the brainstem and autonomic nervous system, which can lower the threshold for a migraine attack. For some people, stress can trigger both conditions in different ways. Managing stress is often an important part of reducing headache frequency and severity.
Can medication overuse make headaches worse?
Yes. Frequent use of pain medicine can lead to medication overuse headache. This occurs when the nervous system becomes more reactive over time, causing headaches to become more frequent or more severe. Medication overuse can affect both migraine and tension-type headaches. Many patients do not realise they have slipped into this pattern until their symptoms escalate. A clinician can help you identify whether medication overuse is contributing to your pain and guide you through safer, more effective strategies for managing headache symptoms.
Why do my headaches switch sides or change in intensity?
Headache location and intensity can vary depending on the underlying mechanism. Migraines often shift from one side of the head to the other, while tension-type headaches usually remain more generalised. Changes in intensity can be influenced by posture, sleep, muscle load, hormonal fluctuations or environmental triggers. Variability does not rule out either condition. What matters is the overall pattern, which a clinician can interpret during assessment.
Is it possible to have both migraine and tension-type headaches at the same time?
Yes. Many patients experience overlapping headache disorders. It is common for someone with tension headaches to also experience episodic migraine, or for chronic migraine to present with tension-like features. This overlap can complicate diagnosis, especially when symptoms evolve over months or years. A clinician can determine whether you are experiencing one condition, two separate conditions, or a blended presentation that is being driven by the same underlying mechanism in the cervical spine or brainstem.
References
Robbins, M.S. (2021) ‘Diagnosis and management of headache: a review’, JAMA, 325(18), pp. 1874–1885. https://doi.org/10.1001/jama.2021.1640.
Stovner, L.J., Nichols, E., Steiner, T.J. et al. (2018) ‘Global, regional, and national burden of migraine and tension-type headache, 1990–2016’, The Lancet Neurology, 17(11), pp. 954–976. https://doi.org/10.1016/S1474-4422(18)30322-3.
Onan, D. et al. (2023) ‘Debate: differences and similarities between tension-type headache and migraine’, The Journal of Headache and Pain, 24, 92. https://doi.org/10.1186/s10194-023-01614-0.
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Disclaimer: This blog is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your healthcare provider with any questions you may have regarding a medical condition or treatment. Never disregard professional advice or delay seeking it based on information you have read here.
