A person sitting with eyes closed, pressing fingers to the temple.

A tension headache is a pain problem: the muscles and soft tissues of the head and neck become tight and sore. A migraine is a neurological event, in which nerve signalling and blood vessel behaviour change across the brain, and pain is only one of the symptoms.

That is why the same tablet can settle one and barely touch the other.

Head pain that needs emergency care

Go to an emergency department or call 995 if a headache comes with any of these:

Sudden, severe pain that peaks within seconds — a “thunderclap” headache
Fever with a stiff neck, or a rash
Confusion, slurred speech, or weakness or numbness on one side
Sudden loss of vision, or a first seizure
A headache after a significant head injury

These are not migraine features. They point to causes that are treated by the hour, including bleeding around the brain — see brain aneurysm and stroke.

Call 995

A standard headache

The commonest is the tension headache, usually brought on by stress, sustained posture, screen time, dehydration or poor sleep.

How it feels: a dull ache, or a tight band around the forehead, temples or back of the head
Where: usually both sides
How bad: mild to moderate; most people carry on with the day
What comes with it: usually nothing — no nausea, no light sensitivity

A migraine

How it feels: throbbing or pulsating, worse when you move or exert yourself
Where: often one side, though it can switch sides or affect both
How bad: moderate to severe, often enough to stop the day entirely
What comes with it: sensitivity to light, sound and smell; nausea and sometimes vomiting
Aura: about a quarter to a third of people get warning symptoms — flashing lights, zigzags, blind spots, or tingling in a hand or the face — before or during the attack

Side by side

	Tension headache	Migraine
Pain	Constant dull ache, or a tight band	Throbbing, pounding
Where	Both sides, forehead or back of the head	Usually one side
Severity	Mild to moderate	Moderate to severe, often disabling
How long	30 minutes to a few hours	4 to 72 hours if untreated
Light and sound	Rarely a problem	Marked sensitivity
Stomach	Nothing	Nausea, vomiting, loss of appetite
Vision	Nothing	Aura in roughly a third

Two other patterns are worth knowing, because they are often mistaken for one of the above: cervicogenic headache, which starts in the neck and is felt in the head, and cluster headache, which is short, one-sided, excruciating, and comes with a red or watering eye.

What helps each one

For tension headaches: water, rest from screens, gentle neck and shoulder stretches, a warm compress, and simple painkillers used sparingly. Where they keep returning, the neck and posture are usually worth assessing rather than the head.

For migraine: a dark, quiet room at the first sign, and medication taken early rather than once the attack is established. Where attacks are frequent, preventive treatment is the aim — fewer and milder attacks rather than better rescue — and a headache diary is how triggers get identified: sleep, hormonal changes, skipped meals, alcohol, specific foods.

Painkillers can become the problem. Taking simple painkillers or migraine medication on more days than not can lead to medication-overuse headache: a daily, dull background headache caused by the treatment. If you are reaching for something most days, that is worth a conversation rather than a larger box.

When to get it looked at

Attacks are frequent or getting worse
Medication is not working, or you are using it most days
The pattern has changed — new features, new location, or a headache unlike your usual one
It is affecting work, driving or family life
You are over 50 and the headaches are new

What we can do here

Headache and migraine are a substantial part of Dr Mathew Tung’s practice, and largely non-surgical. Alongside preventive medication, including CGRP inhibitors, treatment can be directed at the nerves carrying the pain:

Occipital nerve treatments
Sphenopalatine blocks with radiofrequency
Pulsed radiofrequency and other neuromodulation
Cervical epidural injections, where the neck is part of the picture

The aim with frequent migraine is fewer and less severe attacks, rather than only treating each one as it arrives.

Migraine vs headache: how to tell the difference