What you need to know

• Most headaches are either tension-type or migraine — two different conditions that often get blurred together. Telling them apart shapes whether over-the-counter medications are enough or whether prescription treatment is needed.
• Tension-type headaches usually respond to lifestyle changes and over-the-counter pain relievers used sparingly. Migraine often requires migraine-specific medications, both for acute attacks and, when frequent, for prevention.
• A small percentage of headaches are caused by something else entirely — a “secondary” headache that needs urgent evaluation. A short list of red flags helps separate the worrying ones from the merely uncomfortable.

Headache is one of the most common reasons people see a doctor, and it is also one of the most often misdiagnosed. Studies have repeatedly shown that what people think of as “just a tension headache” or “a sinus headache” is frequently migraine in disguise — and the treatments that actually work are different. Getting the diagnosis right is the difference between cycling through over-the-counter pain relievers that barely help and finding a medication that genuinely controls attacks.

This article focuses on how to tell migraine from tension-type headache, when prescription medications come into play, and the warning signs that should prompt a closer look. If you have already been diagnosed with chronic migraine, the deeper conversation about long-term management lives in the article on chronic migraine treatments, triggers, and support.

Telling them apart

The two have overlapping features but distinct patterns. The catch is that nobody experiences a headache and reads off a checklist — symptoms blur, and even specialists sometimes need a few months of headache diary entries to reach a confident diagnosis.

Migraine

• Often one-sided (though it can be bilateral)
• Throbbing or pulsating quality
• Moderate to severe intensity that interferes with daily activities
• Worsened by routine physical activity (walking up stairs, bending over)
• Accompanied by nausea or vomiting, sensitivity to light (photophobia), and sensitivity to sound (phonophobia)
• May be preceded by an aura — visual changes (flashing lights, blind spots), tingling on one side of the body, or speech disturbance — typically lasting 5 to 60 minutes
• Each untreated attack typically lasts 4 to 72 hours

Tension-type headache

• Usually bilateral (both sides) and band-like
• Pressure or tightness rather than throbbing
• Mild to moderate intensity that does not stop activity
• Not worsened by routine physical activity
• Usually no nausea, vomiting, or major sensitivity to light or sound
• Lasts from 30 minutes to several days

In practice, a useful rule of thumb is that a recurring headache that interferes with daily activities is more likely to be migraine than tension-type headache — even when it is bilateral, even when it does not throb, and even when it is sometimes called “sinus” or “stress” headache. Many people with migraine carry a different label for years before getting the right diagnosis.

When over-the-counter medications are enough

For occasional, mild-to-moderate tension-type headaches, simple over-the-counter pain relievers usually do the job. Acetaminophen, ibuprofen, naproxen, or aspirin (alone or in combinations like aspirin-acetaminophen-caffeine) work well. Mild migraine attacks sometimes respond to these too, particularly if taken early in the attack.

There is one important caveat: using over-the-counter pain relievers more than 10 to 15 days per month can paradoxically cause more frequent headaches — a condition called medication-overuse headache. The threshold is roughly 15 days per month for plain acetaminophen or NSAIDs, and 10 days per month for combination products containing caffeine, butalbital, opioids, or for triptans. If you are reaching for pain relief that often, the medications themselves may be part of the problem, and a different approach is needed.

When migraine-specific prescription medications are needed

If migraine attacks are moderate to severe, do not respond to over-the-counter pain relievers, or are interfering with work, family, or daily life, prescription treatment usually helps. Migraine medications fall into two categories: acute (taken to stop an attack in progress) and preventive (taken regularly to reduce how often attacks occur).

Acute treatment

Triptans have been the workhorse of acute migraine treatment for decades. Sumatriptan (Imitrex) was the first; rizatriptan, eletriptan, naratriptan, almotriptan, frovatriptan, and zolmitriptan followed. They work best when taken at the first signs of an attack and come in tablets, dissolving wafers, nasal sprays, and injections. Triptans constrict blood vessels and are generally avoided in people with significant cardiovascular disease, uncontrolled high blood pressure, or a history of stroke.

Gepants are a newer class of acute treatments — ubrogepant (Ubrelvy), rimegepant (Nurtec ODT), and zavegepant (Zavzpret, a nasal spray). They block CGRP, a protein involved in migraine pain, and do not cause vasoconstriction, so they can be used in people who cannot take triptans for cardiovascular reasons. Rimegepant uniquely works for both acute treatment and prevention.

Ditans (lasmiditan, sold as Reyvow) are another option for people who cannot use triptans. They work on a different serotonin receptor and do not constrict blood vessels, but they cause significant drowsiness and require not driving for at least 8 hours after a dose.

Anti-nausea medications (metoclopramide, prochlorperazine, ondansetron) are sometimes added to address the nausea that comes with migraine and can also have headache-relieving effects of their own.

Preventive treatment

Preventive medication is generally considered when migraine attacks happen 4 or more days per month, when attacks are particularly severe or disabling, or when acute treatments are not adequate or not tolerated. The aim is fewer attacks, not necessarily zero.

• Older oral preventives include beta-blockers (propranolol, metoprolol, timolol), antiseizure medications (topiramate, valproate), and tricyclic antidepressants (amitriptyline, nortriptyline). They were not designed for migraine but were found to help, and they remain effective and inexpensive options.
• CGRP monoclonal antibodies — erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality), and eptinezumab (Vyepti) — are migraine-specific preventives given by monthly or quarterly injection (eptinezumab is an IV infusion). They are typically reserved for people whose migraine has not been adequately controlled on older oral preventives.
• Atogepant and rimegepant are oral CGRP receptor antagonists used for prevention.
• Botulinum toxin (Botox) injections are FDA-approved for chronic migraine (15 or more headache days per month).

Treating tension-type headache

For occasional tension-type headache, the basics work: simple over-the-counter pain relievers, hydration, sleep, neck and shoulder stretching, and addressing the root issue when one is identifiable — usually stress, poor posture, eye strain, or muscle tension.

For frequent or chronic tension-type headache (15 or more headache days per month for at least 3 months), preventive treatment is reasonable. Low-dose amitriptyline taken at night is the most established option. Stress management, cognitive behavioral therapy, and physical therapy targeting the neck and shoulders all have evidence behind them. Stress is a particularly common trigger for both tension-type headaches and migraine, and addressing it directly often does more than another medication ever will.

Red flags: when to rule out other causes

A small share of headaches are caused by something else — bleeding in the brain, an infection, a tumor, a clot in a brain vein, an aneurysm, dangerously high blood pressure, temporal arteritis in older adults. The mnemonic SNNOOP10 lists features that should prompt a careful workup, often including imaging.

• Systemic symptoms — fever, unexplained weight loss, night sweats, an immune-suppressed state
• Neurologic symptoms — weakness, numbness, vision changes, confusion, seizure, severe imbalance
• Neoplasm history — a known cancer, especially one that can spread to the brain
• Onset that is sudden, severe, and peaks within seconds to a minute (often called “thunderclap” headache) — possible bleed in or around the brain
• Older age — a new headache after 50 or 65, particularly if combined with scalp tenderness or jaw pain (possible giant cell arteritis)
• Pattern change — a familiar headache that suddenly behaves differently, gets more frequent, or stops responding to usual treatments
• Postural headaches that are dramatically worse standing or sitting up
• Headaches triggered by exertion, coughing, or sex
• Pregnancy or recent childbirth with new headache
• Headache after head injury

When to see a doctor

Make a routine appointment if headaches are interfering with work, sleep, or daily life; if over-the-counter pain relievers are not enough; if you are reaching for them more than a couple of times a week; or if you have not had your headaches formally diagnosed before. A primary care provider can sort most cases — neurology referral is reserved for harder-to-treat or unclear presentations.

Seek urgent or emergency care for any of the SNNOOP10 features above — particularly the worst headache of your life, sudden severe headache that peaks in seconds, headache with new neurologic symptoms (weakness, numbness, slurred speech, confusion, vision loss), headache with high fever and stiff neck, or headache after head injury.

Frequently asked questions