If you’ve ever suffered from any type of headache, you know that there is nothing funny about them. However, because migraines and headaches are not fatal and often do not result in permanent disability for most, their importance to public health has long been understated. This is particularly unfortunate for that subset of patients who are disabled by these afflictions.
Headaches and migraines can knock out even the toughest of us. Understanding the difference between headaches and migraines, though, can help us better treat these problems.
What is a Headache?
According to an article in the American Journal of Medicine, headaches are “an almost universal human experience and are one of the most common complaints encountered in medicine and neurology.” People have been complaining about headaches for all of recorded history and their economic burden on the world is estimated at $14 billion annually.
There are two types of headaches: primary and secondary. These headaches are classified on a chart called The International Classification of Headache Disorders. The primary headaches are those that happen most frequently, like migraine, tension-type, trigeminal-autonomic cephalgia, and others.
The secondary headaches include those caused by trauma, vascular disease, intracranial disorders, substance abuse or withdrawal, infection, or other problems. The biggest difference between primary and secondary headaches is the cause. With a secondary headache, the cause is known; but with primary headaches, there is no known cause.
What is a Migraine Headache?
A 2016 Lancet study found migraine was the second highest cause of disability worldwide. It’s easily the most common neurological disorder in the U.S., affecting almost 20% of women and 6% of men. Migraine also appears to be very common in fibromyalgia and chronic fatigue syndrome (ME/CFS) with incidence rates ranging from 20 to 80%, depending on the study.
One study found that more people with fibromyalgia met the criteria for migraine (56%) than met the criteria for ME/CFS. Having fibromyalgia and migraine appear to open a kind of Pandora’s box of afflictions. People diagnosed with both diseases were also significantly more likely to be diagnosed with hypertension (p<.004), asthma (p<.01), irritable bowel syndrome (p<.02), depression (p<.0002), anxiety ( p<.001), PTSD (p<.005) and, most of all, chronic fatigue syndrome (p<.0001).
Some studies suggest that the blood flow issues, the hypoxia, increased lactate levels in the brain and hypersensitivity reactions found in migraine, fibromyalgia and ME/CFS may link the three disorders together.
The fact that migraine, like chronic fatigue syndrome and fibromyalgia, tends to affect people in the most productive years of their lives (between 18 and 55), makes the disease doubly injurious to society. Yet the NIH spends just $0.67 per migraine patient per year – far below what it provides, even for people with ME/CFS and FM.
For a headache to be classified as a migraine, it must have a few distinct symptoms. Migraines may or may not have auras, which are a “fully reversible set of nervous system symptoms” that will come and go. In many situations, patients will experience a visual aura that is followed by a migraine within 60 minutes.
To be diagnosed as a migraine, sufferers should have at least five severe headaches that typically last between four and 72 hours, with several of these symptoms:
- Pain on one side of the head
- Pulsation at the points of pain
- Moderate to severe pain
- Nausea and/or vomiting
- Pain is aggravated by sound or light
- Pain is aggravated by routine activities.
The American Journal of Medicine reports that migraines usually have four phases: the prodrome (pre-migraine), aura, attack, and postdrome (post-migraine). People who experience regular migraines often recognize the prodrome symptoms (irritability, hyperactivity, euphoria, depression, and food cravings) and know a migraine is on the way. During the postdrome phase, patients often experience ME/CFS-like symptoms (extreme fatigue, confusion) and head pain that occurs when the head is tilted.
Symptoms and Causes of Tension-Type Headaches
A 2016 Lancet study found tension-type headaches to be the third most prevalent disorder worldwide. Like other pain and fatigue disorders, tension-type headaches were originally thought to be pyschogenic in nature. However, further study is revealing a neurobiological basis for them.
Despite their name, tension-type headaches can be caused by different pathologies, possibly mental or muscular. This type of headache is often described as producing dull, pressure like, constricting symptoms or causing a sense of fullness in the head. Quite frequently, tension headache patients describe their pain as like wearing a tight hat or a tight band around the head, or “bearing a heavy burden on the head.”
The location of a typical tension-type headache changes over time. They can be on the left, right, or both sides of the head as well as at the front or back of the head. Sometimes patients with tension headaches can have sound or light sensitivity, but not both concurrently. Tension-type headaches do not cause nausea or vomiting, like migraines do. Patients report that tension-type headaches often begin with mild pain that increases throughout the day.
Tension-type headaches tend to occur when patients are tired, stressed, or hungry. Women sometimes have them during their menstrual cycles. Some patients connect them to drinking alcoholic or caffeinated beverages.
Similarities Between Migraines and Tension-type Headaches
Differentiating between tension-type headaches and mild forms of migraine, which do not produce auras, has been difficult, in part because many people with one may also experience the other.
In a study in the Indian Journal of Psychiatry, researchers seeking to uncover distinct differences between migraine and tension-type headaches found inaccuracies in the diagnostic criteria found in the International Classification of Headache Disorders-2 (ICHD-2). (See the ICHD-3 here.)
Several overlaps between the two types of headaches complicate a diagnosis. The researchers found, for instance, that contrary to accepted knowledge, some migraines can occur on the left and right sides of the head. Plus, not all migraine sufferers had troubles with nausea, vomiting, and light or sound sensitivity, while some tension-type headache sufferers do. Scalp tenderness (allodynia) and blurred vision appear to be relatively common in both conditions.
Differences Between Migraines and Tension-Type Headaches
One goal of the study was to uncover distinct differences in the two types of headaches despite the similarities in symptoms, and the researchers did find some clear differences. Migraine sufferers had more episodes with severe pain when compared to people who had tension-type headaches. In contrast to the relatively stable tension-type headaches, migraines tended to worsen over time (more frequent, more severe and longer duration) with a tendency to become chronic.
Light, noise, odors, moving one’s head, exercising or straining tended to exacerbate migraines but not tension-type (TT) headaches. Lightheadedness was common in migraine and rare in TT headache. While nausea was found in a subset of those with tension-type headaches, it was far more common in migraine. Vomiting occurred in a third of migraineurs but did not occur in TT headache at all. A post-headache period of fatigue and lethargy was much more common in migraine (40%).
Muscle para or dysfunction such as bruxism (teeth grinding, clenched and contracted muscles) and muscle hypertrophy (enlarged muscles) were more common in tension-type headaches.
Pain-killers, interestingly, were more effective in migraine than in tension-type headaches.
Migraineurs also try many more ways to relieve their pain (cold packs, staying in bed, pain-killers, isolating themselves, inducing vomiting, changing diet and remaining immobile) than people with tension-type headaches (scalp massage).
While some triggers for migraine are known (weather, odors, smoke and light), the study suggested that stress is a more common trigger of tension-type headaches than migraine. (Not all TT headaches are caused by stress and not all migraine triggers can be recognized.)
The study was unable to find out why more people miss work due to tension-type headaches, especially since migraines are more frequent, severe, and complicated.
Other Types of Headaches
The International Headache Society lists 14 different kinds of headaches and breaks down each of those into subsets. For instance, it lists over 20 different kinds of migraines.
- Cluster headaches – the most severe headaches of all cluster headaches usually affect men, and are characterized by an intense burning or piercing pain behind or around one eye which reddens, the pupil reduces in size, and/or the eye tears. They tend to occur in groups several times a day for two weeks to three months, lasting each time for 15 minutes to three hours. Often, they are so painful that the person cannot remain still. According to the National Headache Foundation, oxygen, ergotamine; sumatriptan; or intranasal application of a local anesthetic agent may help.
- Sinus headaches – occur when the sinuses or cavities in your head become inflamed, usually from an infection. They produce a deep and constant pain in your cheekbones, forehead, or the bridge of your nose. A runny nose, a feeling of fullness in the ears, fever, and a swollen face may accompany them. The National Headache Foundation recommends antibiotics, decongestants and surgical drainage, if necessary.
- Exertional Headaches – often co-occurring with migraines, these headaches occur when the blood vessels in your head, neck, and scalp swell to provide more blood – causing a pulsing pain on both sides of the head that can last from 5 minutes to 2 days. They can be triggered by physical exercise or by coughing, sneezing, sexual intercourse, and/or straining during a bowel movement. Anti-inflammatories such as indomethacin, Rofecoxib or even aspirin taken before the exertion may help.
Other Headaches to Take Note of in Fibromyalgia and ME/CFS
- POTS (postural orthostatic tachycardia syndrome) headaches – many people with POTS have orthostatic headaches which occur when they stand up.
- Craniocervical Instability (CCI) – not typically mentioned in headache classifications, CCI often causes a feeling of a “heavy headache which feels like the head is too heavy for the neck to support”. Plus, an impairment of cerebral spinal fluid can cause “pressure headaches” that are aggravated by yawning, laughing, crying, coughing, sneezing or straining. Other symptoms can include neck pain, dysautonomia, POTS, balance problems, vertigo, muscle weakness, fatigue, etc. See Jeff’s ME/CFS CII story here.
- Cerebral Spinal Fluid Leak headaches – caused by low spinal fluid pressure, CSF headaches are characterized by a headache that occurs when one is upright (sitting or standing) or when one raises one’s head from the bed, which improves when one is lying down. One test is to determine if lying flat with one’s head lower than one’s body causes symptoms. Other CSF leak symptoms can include neck pain, neck stiffness, nausea, vomiting, sensitivity to light and/or sound, sense of imbalance, ringing in the ears and changes in hearing. Check out Caroline’s ME/CFS, POTS, EDS, spinal fluid leak story here.
- Chiari Malformation headaches – are characterized by headaches which begin at the back of the head (neck) and radiate upwards. Coughing, sneezing or straining can bring on these headaches. Other symptoms of Chiari malformation include double or blurred vision, balance problems, vertigo and dizziness, breathing problems, muscle weakness, gagging, swallowing difficulties, facial numbness or syncope (temporary loss of consciousness).
Record Your Headaches
One way to determine what type of headaches you get is to keep a record of them. Journaling the symptoms and when they occur will help you better explain your experiences to your health care provider. When you record the experiences, note the date, time of day, and exactly what you are experiencing. If you do take medication, record when you took it and whether or not it was helpful. Check out a headache diary form from the National Headache Foundation here.
Since tension-type headaches are often triggered by stress, it is also important to note how you are feeling at the time a headache arises. You could record:
- How you are feeling physically
- How much sleep you got the previous night
- What stress is happening in your life.
According to the study in the Annals of Indian Academy of Neurology, people who experience tension-type headaches often do not seek medical treatment. Instead, they self-medicate with over-the-counter pain medication like ibuprofen or acetaminophen. The study also reports that absenteeism from work in the United States and Europe due to tension-type headaches can be three times higher than absenteeism from migraines.
Regardless of the type of headache you get, it is important to take care of yourself. Health care providers can help you manage both migraines and tension-type headaches.
About Dr. Wells
Serving Wasilla, Anchorage, and the surrounding communities, Dr. Brent Wells offers patient-centered, personalized, and innovative chiropractic care. A California native, Dr. Wells earned a Bachelor of Science degree from the University of Nevada. He then attended Western States Chiropractic College in Portland, Oregon. In 1998, he and his wife Coni moved to Alaska and opened Better Health Chiropractic in Juneau. .
He is a proud member of the American Chiropractic Association and the American Academy of Spine Physicians, and has authored over 700 online health articles which have been featured on sites such as Dr. Axe and Lifehack. He’s committed to remain updated on studies related to neurology, physical rehab, biomechanics, spine conditions, brain injury trauma, and more
Headache Resources on Health Rising
Register for our free ME/CFS, fibromyalgia, and long COVID blogs here.