Migraine vs Tension Headache: How to Tell the Difference and Seek Treatment

Headache is among the most common reasons for medical consultation worldwide. In Nepal, headache accounts for a significant proportion of neurology outpatient visits. Yet most people with migraine in Nepal have never received a formal diagnosis — they describe themselves as having “headache” and manage with whatever analgesic is available at the pharmacy. Accurate classification matters because the treatment for migraine is different from tension headache, and treating the wrong type leads to either inadequate relief or medication-overuse headache, which makes the situation worse.

What Are the Defining Characteristics of Migraine?

Migraine is a neurological disorder characterised by recurrent attacks of moderate to severe headache, typically unilateral and throbbing, lasting 4–72 hours, and accompanied by nausea, vomiting, and sensitivity to light and sound. At least two of four pain features and at least one associated symptom are required for the clinical diagnosis.

The word “migraine” comes from hemicrania — half skull — reflecting its characteristic unilateral location, though up to 40% of migraine sufferers have bilateral pain. The throbbing quality and the severe worsening with routine physical activity (such as walking up stairs) are other distinguishing features.

Approximately one-third of migraine patients experience aura — reversible neurological symptoms that develop over 5–20 minutes and precede or accompany the headache. Visual aura is most common: patients describe shimmering zigzag lines (fortification spectra), blind spots, or flashing lights. Sensory aura (tingling spreading up an arm) and speech aura also occur. Aura without headache (silent migraine) is possible.

The interictal period — between attacks — is normal in migraine. This is important: migraine is episodic. Patients are well between attacks, which helps distinguish it from tension-type headache that is often chronic and daily.

How Is Tension-Type Headache Different From Migraine?

Tension-type headache is bilateral, described as a pressing or tightening sensation (like a tight band around the head), mild to moderate in severity, and does not worsen with routine activity. It is not accompanied by nausea or vomiting. While photophobia or phonophobia may occur, both together are unusual.

The mechanism of tension-type headache is incompletely understood but involves peripheral sensitisation of pericranial muscles. Stress, poor posture, sleep deprivation, and prolonged screen use are common triggers. It is the most prevalent headache type globally.

Treatment of episodic tension-type headache is straightforward: simple analgesics (paracetamol, ibuprofen) are effective. The problem arises when headache frequency increases and analgesics are used on more than 10–15 days per month — this produces medication-overuse headache (MOH), which is chronic, daily, and responds poorly to the same analgesics. Withdrawal of the overused medication is the cornerstone of MOH treatment.

What Is a Cluster Headache?

Cluster headache is rare — affecting approximately 0.1% of the population — but it is the most severe primary headache disorder. Attacks are strictly unilateral, centred around or behind one eye, and are excruciating in intensity. They last 15 minutes to 3 hours but occur in clusters — multiple attacks per day for weeks to months, followed by periods of remission.

Autonomic features are diagnostic: during an attack, patients have ipsilateral (same-side) tearing, nasal congestion or discharge, eyelid drooping, and conjunctival injection. Unlike migraine patients who lie still, cluster headache patients are typically agitated, pacing, unable to rest.

Treatment is acute (high-flow 100% oxygen, subcutaneous sumatriptan) and preventive (verapamil is first-line). Cluster headache is under-diagnosed in Nepal and frequently mismanaged as sinusitis or dental pain.

Which Headaches Are Red Flags That Require an Urgent Scan?

Certain headache features should prompt immediate medical assessment and imaging — they indicate potentially serious secondary causes including subarachnoid haemorrhage, intracranial infection, or tumour.

A thunderclap headache — reaching maximum severity within 60 seconds — must be presumed to be subarachnoid haemorrhage until proven otherwise by CT scan and lumbar puncture. This is the “first and worst” headache that patients often describe as unlike any previous headache.

Progressive worsening headache over days to weeks, headache accompanied by fever and neck stiffness (meningism), headache with new neurological symptoms (weakness, vision loss, speech change), headache in someone with cancer or HIV, and headache beginning after age 50 for the first time are all red flags requiring investigation rather than empirical treatment.

What Triggers Migraine and How Can They Be Managed?

Common migraine triggers include sleep disruption (both too little and too much), hormonal changes (menstruation is the most common trigger in women), certain foods and drinks (red wine, aged cheeses, caffeine withdrawal), dehydration, prolonged fasting, bright or flickering light, and emotional stress.

Trigger identification is done through a headache diary — recording each attack’s timing, duration, severity, associated symptoms, and potential triggers for at least 8 weeks. Not all apparent triggers are truly causal; some foods or activities identified as triggers may simply be early migraine symptoms (premonitory phase) rather than causes.

Trigger avoidance is a component of management but should not become a source of anxiety that itself triggers migraine. The goal is not to live a restricted life but to identify genuinely modifiable factors.

What Is the Difference Between Abortive and Preventive Migraine Treatment?

Abortive treatment is taken when a migraine attack begins, with the goal of aborting or shortening it. Triptans (sumatriptan, rizatriptan) are the most effective abortive medications for moderate to severe migraine. Simple analgesics such as aspirin or ibuprofen combined with an antiemetic work for mild attacks.

Preventive treatment is taken daily to reduce attack frequency and severity. It is considered when attacks occur more than 4 days per month or are substantially disabling. Options include propranolol, amitriptyline, sodium valproate (with contraception in women of childbearing age), topiramate, and the newer CGRP pathway antagonists (where available).

A common error in Nepal is relying exclusively on analgesics — including combination analgesics — for frequent migraine without ever receiving appropriate abortive or preventive treatment. This trajectory reliably leads to MOH.

How Does Altitude Headache Differ From Migraine in Pokhara?

Pokhara sits at approximately 827 metres above sea level, which is not high enough to cause altitude sickness in most individuals. However, many patients and trekkers passing through Pokhara are ascending to significantly higher elevations — Annapurna Base Camp at 4,130 m, Thorong La at 5,416 m.

Altitude (acute mountain sickness) headache is bilateral, worsened by bending forward or exertion, and accompanied by fatigue, poor sleep, and loss of appetite. It occurs above 2,500 m. It does not have the throbbing unilateral quality of migraine, and aura is absent.

Migraine patients ascending altitude may find that the combination of exertion, dehydration, and disrupted sleep reliably triggers attacks. These individuals benefit from pre-trek planning, adequate hydration, and ensuring they carry their prescribed triptan.

A&B International Hospital

Pokhara-02, Bindhyaabasini Way to Sarangkot

Phone: +977 061-412512

Website: abinthospital.com

Frequent or disabling headaches deserve proper neurological assessment, not repeated analgesic prescriptions. A&B International Hospital’s neurology team offers headache diagnosis, trigger analysis, and evidence-based treatment in Pokhara. ECHS polycards accepted.