It was never just tension

Someone told you it was tension. Stress, screens, the way you sit. It sounded plausible, so you took the advice, bought a better chair and got on with things. The headaches kept coming anyway. If nothing you have done about the tension has touched them, it is worth asking whether the label was right in the first place.

What tension-type headache actually is

Tension-type headache has a proper definition, and it is narrower than most people assume. The international classification describes pain on both sides of the head, pressing or tightening rather than throbbing, mild to moderate in intensity, and not made worse by ordinary activity such as walking upstairs. There is no nausea. There may be some sensitivity to light or to sound, but not both.

Read that list again and notice how much of it is defined by absence. Tension-type headache is, in large part, the headache that does not do the other things. It is genuinely common, and for many people it is mild and responds to simple measures. The trouble starts when it becomes the default answer for any headache that did not arrive with flashing lights and vomiting.

Why migraine so often gets called tension

Migraine does not always look like the textbook picture. Plenty of attacks are moderate rather than disabling, whilst more often than not they are unilateral this is not always true, particularly for subsets of patients such as children, and they can be dull rather than pulsing. What gives migraine away is usually the other symptoms that tag along: the pain worsening when you move, a queasiness and aversion to even pleasant smells, the pull towards a dark quiet room and the flat, foggy day that follows.

Then there is the neck. A pooled analysis of the research found neck pain present in around 77% of people with migraine, compared with about 23% of people without headache. A stiff, aching neck alongside a headache reads as tension to almost everyone, patients and clinicians alike. Often it is not the cause of the attack at all. It is part of it.

This is not a rare mix-up. In a large international study of people consulting their doctor about headache, diaries of their actual attacks were reviewed by an expert panel who did not know what the clinic had decided. Among those given a non-migraine diagnosis, 82% turned out to meet the criteria for migraine or probable migraine. Worth saying plainly: those were people who had gone to their doctor about headaches, so the finding does not apply to everyone with a tension label. It does show which way the error tends to run.

The correct diagnosis is important

A label is not just tidiness on your record; it decides what treatment path you get offered. Migraine has specific acute treatments, a range of preventive options when attacks are frequent, and a set of questions about hormones, sleep, hypermobility and painkiller use. Tension-type headache tends to route you towards over-the-counter pain relief and general advice about stress, which is next to useless and feels dismissive if migraine is what you actually have.

The guidance is clearer on this than the average appointment allows time for. NICE advises that where features of migraine are present alongside chronic tension-type headache, migraine is the diagnosis to work from. In other words, migraine features take priority. If you have them, they should be counted.

It also changes how the neck is handled. Treating a tight, sensitised neck is often useful and can make a real difference to how attacks feel. But it works better as one part of a plan than as the whole answer, and framing it as the sole cause tends to leave people disappointed when the headaches carry on.

What to take to your next appointment

You do not need a perfect diary. A few specifics, gathered over a month or so, usually shift the conversation more than any amount of describing how bad it feels.

• What movement does. Does bending, climbing stairs or rushing for a train make the pain worse? This one question separates the two conditions more often than any other.
• Any nausea at all. Even mild queasiness or going off food counts, and it is the detail people most often leave out.
• What you want during an attack. Dark and quiet, or able to carry on with the radio on.
• The days either side. Yawning, cravings, irritability or a heavy fog the day after are all part of the migraine picture.
• The pattern across the month, including where attacks sit in your cycle if you have one.

If the label never fitted

Being handed the wrong name is rarely anyone behaving badly. Appointments are short, the two conditions overlap, and headache gets very little space in most clinical training. But if "it is just tension" never quite sat right with you, that instinct is usually worth following. You have watched these headaches more closely than anyone.

A proper assessment takes the time to work through what your attacks actually do, checks the things that need checking, and arrives at a name that fits. From there the options open up considerably.

If your headaches have never quite matched the label you were given, a full assessment can help you work out what is actually going on and what to do about it. You are welcome to book an appointment or get in touch.

• International Classification of Headache Disorders, 3rd edition (ICHD-3), sections 1 (Migraine) and 2 (Tension-type headache). ichd-3.org
• National Institute for Health and Care Excellence (NICE). Headaches in over 12s: diagnosis and management (CG150). nice.org.uk/guidance/cg150
• Al-Khazali HM, Younis S, Al-Sayegh Z, Ashina S, Ashina M, Schytz HW. Prevalence of neck pain in migraine: a systematic review and meta-analysis. Cephalalgia, 2022;42(7):663-673.
• Tepper SJ, Dahlof CG, Dowson A, et al. Prevalence and diagnosis of migraine in patients consulting their physician with a complaint of headache: data from the Landmark Study. Headache, 2004;44(9):856-864.
• The Migraine Trust. Types of migraine and tension-type headache. themigrainetrust.org

This article is general information, not a diagnosis or a substitute for individual medical advice.