Most people who think they have a "sinus headache" or a "bad tension headache" actually have migraine — and this mislabeling delays effective treatment by an average of 2–3 years. Knowing the difference isn't trivia; it changes what works.
The 5-Question Quick Screen
The ID Migraine screener, validated in multiple studies, asks just three questions. Two out of three "yes" answers make migraine likely:
- Has a headache limited your activities for a day or more in the last 3 months?
- Do you feel nauseated or sick to your stomach during a headache?
- Does light or sound bother you during a headache?
Add two more: Is the pain one-sided? and Does it throb or pulsate? — and you have a strong clinical picture of migraine versus tension-type.
Location and Quality: A Tale of Two Headaches
Tension-type headaches typically produce a band-like, pressing or tightening sensation — "like a tight cap around the head" — that is bilateral and mild to moderate. You can often function through it.
Migraine pain is usually unilateral, pulsating, and moderate to severe — worsening with routine activity like climbing stairs. Nausea, vomiting, photophobia (light sensitivity), and phonophobia (sound sensitivity) are hallmark associated features.
Why the Confusion Is So Common
About 40% of migraine sufferers also report neck pain, and many experience bilateral pain — both features classically taught as "tension" signs. Furthermore, migraine can produce autonomic symptoms (nasal congestion, tearing) that mimic sinus disease. Underdiagnosis is the rule, not the exception.
Treatment: What Works for Each
- Tension headache: Simple analgesics (ibuprofen, acetaminophen), stress management, neck stretching, and trigger avoidance usually suffice.
- Migraine: Triptans (e.g., sumatriptan) are the first-line abortive for moderate-to-severe attacks. CGRP antagonists (gepants) are a newer option with fewer vascular side effects. Preventives — from beta-blockers to anti-CGRP monoclonal antibodies — are considered when attacks exceed 4 days per month.
Red Flags: When "Just a Headache" Is More
Seek urgent evaluation if your headache is:
- Thunderclap onset — reaching maximal intensity in under 60 seconds
- New after age 50
- With fever, stiff neck, or rash
- With focal neurological symptoms (weakness, vision loss, confusion)
- Worsening over weeks with no clear pattern
The Bottom Line
If your headache stops you in your tracks, comes with nausea or light sensitivity, and beats like a drum on one side of your head — that's probably migraine, and a triptan may break it in 2 hours. If it's a dull pressure that lets you keep working, tension-type strategies will carry you through. Knowing which is which is the first step toward relief.