What is the difference between migraine and tension headache?

Migraine is typically one-sided, throbbing, moderate-to-severe in intensity, and accompanied by nausea, light sensitivity, or sound sensitivity. It usually worsens with routine activity and lasts 4–72 hours untreated. Tension-type headache (TTH) is bilateral, pressing or tightening (not throbbing), mild-to-moderate, and not usually worsened by routine activity. It lacks the nausea or combined photo- and phonophobia of migraine. Many people have both conditions at different times; accurate classification matters because treatment differs. A headache diary over four weeks — recording character, timing, triggers, and medication use — is the single most useful diagnostic tool.

Should I take pain relief every time I get a headache?

Taking acute pain relief — whether paracetamol, NSAIDs, or triptans — more often than ten to fifteen days per month creates a risk of medication-overuse headache (MOH): a paradoxical increase in headache frequency driven by overuse of the very medication intended to treat it. The rule of thumb is to limit any acute headache medication to two days per week or fewer. If you are using acute treatment more often than this, discuss prevention with your GP. Adding a daily preventive medication is usually more effective than escalating acute medication use.

What triggers migraine and how do I identify mine?

Migraine triggers are highly individual and can vary from attack to attack. Common triggers include: stress (and the let-down period after stress), poor or excess sleep, dehydration, skipped meals, hormonal changes around menstruation, barometric pressure changes, bright or flickering light, and strong odours. Alcohol — particularly red wine — and caffeine withdrawal are also frequent triggers. A headache diary app (Migraine Buddy or N1-Headache) tracks attacks, potential triggers, and medication use over time, making patterns visible. Broad food-elimination diets have weak evidence; diary-driven individual identification works better.

When is daily preventive medication worth trying?

Prevention is worthwhile when migraine occurs four or more times per month, when attacks are particularly disabling, when acute treatments are failing or being overused, or when you have hemiplegic migraine or prolonged aura. First-line preventives your GP can prescribe include propranolol (helpful if you also have anxiety or high blood pressure), amitriptyline (useful with comorbid insomnia or tension headache), candesartan (blood-pressure-neutral option), and topiramate (PBS Authority Required for migraine; weight loss is a common side effect). Prevention requires 8–12 weeks at an adequate dose to assess benefit, and a headache diary to measure response.

What is medication-overuse headache and how is it treated?

Medication-overuse headache (MOH) occurs when acute headache medication is taken on 10 or more days per month for simple analgesics, triptans, or combination products for three or more months, in a person who already has a primary headache disorder. MOH typically presents as a daily or near-daily dull background headache. Treatment involves withdrawing the overused medication — which causes a temporary worsening for one to two weeks before improvement — combined with starting a preventive agent. Naproxen or a short course of prednisolone may help bridge the withdrawal period. Your GP can guide this process; specialist referral is available for complex cases.

What are CGRP therapies and can I access them in Australia?

Calcitonin gene-related peptide (CGRP) therapies are a newer class of migraine-specific treatments. Monoclonal antibodies (fremanezumab, galcanezumab, eptinezumab) given by monthly or quarterly injection or infusion are PBS Authority Required for chronic migraine — defined as 15 or more headache days per month for at least six months — after failure of at least three prior preventive medications. They are specialist-initiated and require documented response at six months. Gepants (rimegepant, atogepant) are TGA-approved but not yet PBS-listed and remain expensive on private prescription. Erenumab is TGA-approved but also not PBS-listed as of mid-2026.

Migraine, tension-type headache, and medication-overuse headache

Migraine and tension headache: treatment, prevention and warning signs

By Dr HB Lo, FACRRM Reviewed 21 June 2026 10 min read

Migraine affects about 14% of Australians and leads disability in women under 50. Features: moderate-to-severe throbbing pain lasting 4–72 hours, nausea, light and sound sensitivity. Migraine with aura adds reversible visual or sensory changes before the headache.

Early treatment — paracetamol or NSAID plus antiemetic for mild attacks, a triptan for moderate-to-severe — relieves most episodes. Prevention is warranted when attacks occur four or more days per month.

Tension-type headache is bilateral, pressing, mild-to-moderate, lacking nausea and throbbing. Red flags — thunderclap onset, new focal neurology, fever with neck stiffness — require urgent assessment.

Headache is one of the most common presenting complaints in Australian general practice. Primary headache disorders — those not caused by an underlying structural problem — account for the vast majority. Migraine and tension-type headache together affect more than half the adult population at some point in their lives. Understanding which type is present, whether prevention is worthwhile, and when a headache needs urgent assessment are the three most important clinical questions.

This article focuses on migraine, tension-type headache, and medication-overuse headache. Cluster headache — a rarer but intensely severe type — is also briefly discussed.

A. Core clinical — the AU general-practice framework

Classification — the ICHD-3 framework

Headaches are classified using the International Classification of Headache Disorders (3rd edition). The main primary headache types relevant to general practice are:

Migraine without aura — at least five attacks, each lasting 4–72 hours, with at least two of: unilateral location, pulsating quality, moderate-to-severe intensity, or aggravation by routine physical activity. Plus at least one of: nausea or vomiting, or combined photophobia and phonophobia.

Migraine with aura — fully reversible focal neurological symptoms (most commonly a scintillating visual zigzag pattern called a fortification spectrum, or spread of tingling numbness) developing gradually over at least five minutes and lasting five to sixty minutes, typically preceding the headache. At least two attacks are required for diagnosis.

Chronic migraine — headache on 15 or more days per month for more than three months, of which at least eight days fulfil migraine criteria. Episodic migraine is fewer than fifteen headache days per month.

Tension-type headache (TTH) — bilateral, pressing or tightening quality (non-pulsating), mild-to-moderate intensity, not aggravated by routine activity. No nausea; at most one of photophobia or phonophobia (not both). Frequent episodic TTH is one to fourteen headache days per month; chronic TTH is fifteen or more days per month.

Medication-overuse headache (MOH) — headache on fifteen or more days per month in a person with pre-existing primary headache who takes acute medication on ten or more days per month for triptans, ergots, opioids, or combination analgesics, or on fifteen or more days per month for simple analgesics, for more than three months.

Excluding secondary causes — the SNOOP4 screen

Before diagnosing a primary headache disorder, secondary causes must be excluded. The SNOOP4 mnemonic covers the red flags that require urgent investigation or same-day assessment per RACGP and eTG:

Systemic features — fever, weight loss, immunocompromise, malignancy, anticoagulation
Neurological signs or symptoms — focal weakness, altered consciousness, papilloedema, cerebellar signs
Onset sudden — “thunderclap” headache reaching maximum intensity within seconds to minutes → subarachnoid haemorrhage until proven otherwise
Older age — new headache in anyone over 50: consider giant cell arteritis (temporal arteritis) and intracranial pathology
Pattern change — progressive worsening, qualitative change, escalating frequency
Postural component or Valsalva-provoked — suggests raised intracranial pressure, cerebrospinal fluid leak, or venous thrombosis
Papilloedema on fundoscopy — raised intracranial pressure
Pregnancy or postpartum — venous sinus thrombosis, eclampsia, reversible cerebral vasoconstriction syndrome

Any SNOOP4 feature requires urgent imaging (CT or MRI brain) and/or same-day specialist review, not empirical headache treatment.

The history and headache diary

A headache diary is the single most useful assessment tool, providing at least four weeks of data on:

Number of headache days per month
Attack character, location, duration, severity
Associated features (nausea, photo- and phonophobia, aura)
Potential triggers
Acute medication type and number of use-days per month (essential for MOH screening)
Menstrual timing in women

Free apps — Migraine Buddy, N1-Headache — make this feasible without paper diaries.

Risk factors for migraine progression to chronic migraine include: obesity, poor sleep, depression and anxiety, caffeine overuse, and acute medication overuse. Identifying and addressing modifiable factors is part of every review.

Investigation

Most primary headaches are diagnosed clinically without investigation per eTG. MRI brain is indicated for: any SNOOP4 red flag, new aura in someone aged 40 or over, hemiplegic or brainstem aura, unexplained progressive worsening, or exertional, cough-provoked, or positional headache. ESR and CRP are ordered the same day when giant cell arteritis is clinically possible — do not wait for a morning result before starting prednisolone if clinical suspicion is high.

B. Acute migraine treatment — a step-by-step approach

Step 1 — mild to moderate attacks

Per eTG and AMH, first-line acute treatment for mild-to-moderate migraine is:

Paracetamol 1 g taken early in the attack
NSAID — ibuprofen 400–600 mg, naproxen 500–750 mg, or aspirin 900 mg
Antiemetic — metoclopramide 10 mg or prochlorperazine 5–10 mg — given not only for nausea but to improve gastric motility and therefore analgesic absorption during attacks

Taking medication at the first sign of an attack — before the headache fully establishes — improves response rates significantly.

Opioids and combination analgesics containing codeine carry a high risk of medication-overuse headache and are not recommended for routine migraine management by Australian Prescriber.

Step 2 — moderate to severe attacks (or step-1 failure)

Triptans (5-HT₁B/1D agonists) are the class of choice for moderate-to-severe migraine. Common PBS-listed options include:

Sumatriptan 50–100 mg oral; 6 mg subcutaneous injection (fastest onset, useful when vomiting prevents oral intake); 20 mg nasal spray
Rizatriptan 10 mg orally disintegrating tablet (wafer — useful with nausea)
Eletriptan 40 mg (high efficacy, lower recurrence rate)
Naratriptan 2.5 mg (slower onset, lower recurrence — option for extended attacks or menstrual migraine)

Combining a triptan with an NSAID produces better response and less headache recurrence than either alone.

Triptan contraindications include ischaemic heart disease, uncontrolled hypertension, cerebrovascular disease, hemiplegic or brainstem-aura migraine, peripheral arterial disease, and concomitant ergot use within 24 hours. Use in pregnancy is case-by-case; sumatriptan has the most accumulated pregnancy safety data.

Limit triptans to ten or fewer days per month to avoid medication-overuse headache.

If two different triptans have each failed at an adequate dose across three attacks, switching triptan class or referring to a neurologist is appropriate.

Step 3 — refractory or in-clinic rescue

For attacks refractory to standard acute treatment or managed in a clinic or emergency setting: IV or IM prochlorperazine, IV metoclopramide, IV magnesium sulfate 1–2 g, IV ketorolac, or a greater occipital nerve block with local anaesthetic can provide relief.

Gepants — small-molecule CGRP receptor antagonists — are TGA-approved in Australia. Rimegepant (Nurtec ODT 75 mg) is approved for both acute and preventive use and is particularly useful where triptans are contraindicated due to cardiovascular disease. As of mid-2026, gepants are not PBS-listed and are available only on private prescription at significant out-of-pocket cost.

C. Migraine prevention — who, when, and what

When to consider prevention

Prevention is indicated when migraine causes significant disability on four or more days per month, when acute treatments are being overused, when acute treatments have failed or are contraindicated, or when the pattern is hemiplegic or prolonged aura.

Start with a headache diary baseline for four weeks. Choose a preventive based on comorbidities and tolerability. Assess response after eight to twelve weeks at the target dose, using the diary to measure change in monthly headache days. A 50% reduction in headache days is the standard threshold for continuing a preventive.

First-line GP-initiated preventives

Per eTG and Australian Prescriber — migraine:

Propranolol 40 mg twice daily, titrated to 80–160 mg per day. Useful with comorbid anxiety, hypertension, or essential tremor. Avoid in asthma and depression.
Amitriptyline 10 mg at night, titrated to 25–75 mg. Useful with comorbid tension-type headache, insomnia, or neuropathic pain. Anticholinergic side effects; weight gain.
Candesartan 8–16 mg daily. Comparable to propranolol in head-to-head trials; well tolerated; useful with comorbid hypertension.
Topiramate 25 mg nightly, titrated to 50–100 mg twice daily. PBS Authority Required for migraine prevention; weight loss is common. Causes paraesthesia, cognitive slowing in some. Teratogenic — contraindicated in pregnancy and reduces combined oral contraceptive efficacy at doses ≥200 mg per day; adequate contraception must be confirmed before prescribing.

Specialist-prescribed CGRP monoclonal antibodies

For refractory chronic migraine (15 or more headache days per month for at least six months, with at least eight meeting migraine criteria, after failure of at least three oral preventives including topiramate, propranolol, and amitriptyline, plus management of any medication-overuse headache), neurologist-initiated CGRP monoclonal antibodies are PBS Authority Required:

Fremanezumab (Ajovy) — monthly or quarterly subcutaneous injection; also PBS-listed for high-frequency episodic migraine (8–14 days/month)
Galcanezumab (Emgality) — monthly subcutaneous injection
Eptinezumab (Vyepti) — IV infusion every 12 weeks; PBS-listed since August 2023

Continuation requires documented ≥50% reduction in monthly headache days at six months. Erenumab (Aimovig) is TGA-approved but not PBS-listed.

Botulinum toxin A (onabotulinumtoxinA, PREEMPT protocol, 155 units every 12 weeks) is also PBS Authority Required for refractory chronic migraine, specialist-prescribed, with the same continuation criteria.

D. Australian operations

Medications — PBS access

Triptans (sumatriptan, rizatriptan, eletriptan, zolmitriptan, naratriptan) are all PBS-listed under Streamlined Authority for migraine. Paracetamol, ibuprofen, naproxen, metoclopramide, and prochlorperazine are standard PBS. First-line preventives (propranolol, amitriptyline, candesartan, verapamil) are on standard PBS. Topiramate requires Authority for the migraine indication. Sodium valproate is PBS Authority; the TGA has issued a black-box warning for valproate in women of childbearing potential due to teratogenicity — a pregnancy prevention programme is mandatory when prescribing valproate to women who may become pregnant.

GP care planning and mental health

Chronic migraine with comorbid depression or anxiety — which is common — qualifies for a Mental Health Treatment Plan (MBS items 2715/2717), providing subsidised psychology sessions for cognitive behavioural therapy, biofeedback, and mindfulness-based stress reduction — all with evidence for migraine prevention.

Chronic migraine with comorbidities also qualifies for GP Chronic Condition Management Plan (GPCCMP, MBS items 965/967) for allied health referrals including physiotherapy and dietitian support.

Australian consumer resources

E. Special populations

Pregnancy. Preferred acute treatment: paracetamol in any trimester; avoid NSAIDs in the third trimester. Sumatriptan has the most reassurance data of the triptans during pregnancy. Preferred preventive if required: propranolol (lowest risk) or low-dose amitriptyline. Avoid topiramate (cleft palate risk), valproate (neural tube defects and neurodevelopmental harm — TGA black-box warning), and candesartan (fetotoxic). CGRP monoclonal antibodies — no human pregnancy safety data; avoid.

Oral contraception and migraine. Combined oral contraceptives (oestrogen-containing) are contraindicated in migraine with aura due to an increased stroke risk. In migraine without aura, combined oral contraceptives carry a small absolute increased risk; the progesterone-only pill, implant, or intrauterine device are preferred options. Discuss the risk-benefit balance at each review.

Menopause. Continuous transdermal oestrogen (and progesterone if not hysterectomised) is generally preferred over cyclical or oral HRT in menopausal migraineurs, as it avoids the oestrogen fluctuations that trigger attacks. Discuss with an appropriate clinician and review at three months.

Cluster headache. Cluster headache — severe, strictly unilateral orbital pain lasting 15–180 minutes with ipsilateral autonomic features (tearing, nasal congestion, ptosis) — is treated acutely with 100% oxygen 12–15 L/min via non-rebreather mask, or sumatriptan 6 mg subcutaneous injection per Australian Prescriber — cluster headache. Prophylaxis requires verapamil with serial ECG monitoring. Cluster headache warrants referral to a neurologist for ongoing management.

When to escalate

Present to your nearest emergency department immediately for:

Thunderclap headache — pain reaching peak intensity within 60 seconds (subarachnoid haemorrhage until proven otherwise)
Headache with fever, neck stiffness, and rash (meningococcal meningitis)
Headache with new focal weakness, speech difficulty, vision loss, or altered consciousness
Headache with papilloedema or marked hypertension

See your GP urgently (within 24–48 hours) for:

New headache in anyone over 50
Headache that is qualitatively different from your usual pattern
Headache worsened by lying down, coughing, or Valsalva manoeuvre
Headache with jaw pain or scalp tenderness in an older person (giant cell arteritis)
Status migrainosus — migraine lasting more than 72 hours

Routine GP referral to a neurologist is appropriate when: episodic migraine is not controlled after two first-line preventives at adequate dose; diagnostic uncertainty persists; cluster headache is suspected; or the patient qualifies for CGRP monoclonal antibody therapy.

What this article is and is not

This article draws on current Australian general practice guidelines — Therapeutic Guidelines (eTG), Australian Medicines Handbook, RACGP resources, Australian Prescriber, Migraine and Headache Australia, and Migraine Australia — to provide general health information about migraine and tension-type headache. It is not personal medical advice and does not create a doctor–patient relationship.

All treatment decisions — including which preventive to try, whether triptans are appropriate for you, and when specialist referral is warranted — are made with your own GP or treating clinician based on your individual history and circumstances.

For consumer-friendly information: Migraine and Headache Australia, Migraine Australia, HealthDirect.

Sources cited

Frequently asked questions

What is the difference between migraine and tension headache?

Migraine is typically one-sided, throbbing, moderate-to-severe in intensity, and accompanied by nausea, light sensitivity, or sound sensitivity. It usually worsens with routine activity and lasts 4–72 hours untreated. Tension-type headache (TTH) is bilateral, pressing or tightening (not throbbing), mild-to-moderate, and not usually worsened by routine activity. It lacks the nausea or combined photo- and phonophobia of migraine. Many people have both conditions at different times; accurate classification matters because treatment differs. A headache diary over four weeks — recording character, timing, triggers, and medication use — is the single most useful diagnostic tool.
Should I take pain relief every time I get a headache?

Taking acute pain relief — whether paracetamol, NSAIDs, or triptans — more often than ten to fifteen days per month creates a risk of medication-overuse headache (MOH): a paradoxical increase in headache frequency driven by overuse of the very medication intended to treat it. The rule of thumb is to limit any acute headache medication to two days per week or fewer. If you are using acute treatment more often than this, discuss prevention with your GP. Adding a daily preventive medication is usually more effective than escalating acute medication use.
What triggers migraine and how do I identify mine?

Migraine triggers are highly individual and can vary from attack to attack. Common triggers include: stress (and the let-down period after stress), poor or excess sleep, dehydration, skipped meals, hormonal changes around menstruation, barometric pressure changes, bright or flickering light, and strong odours. Alcohol — particularly red wine — and caffeine withdrawal are also frequent triggers. A headache diary app (Migraine Buddy or N1-Headache) tracks attacks, potential triggers, and medication use over time, making patterns visible. Broad food-elimination diets have weak evidence; diary-driven individual identification works better.
When is daily preventive medication worth trying?

Prevention is worthwhile when migraine occurs four or more times per month, when attacks are particularly disabling, when acute treatments are failing or being overused, or when you have hemiplegic migraine or prolonged aura. First-line preventives your GP can prescribe include propranolol (helpful if you also have anxiety or high blood pressure), amitriptyline (useful with comorbid insomnia or tension headache), candesartan (blood-pressure-neutral option), and topiramate (PBS Authority Required for migraine; weight loss is a common side effect). Prevention requires 8–12 weeks at an adequate dose to assess benefit, and a headache diary to measure response.
What is medication-overuse headache and how is it treated?

Medication-overuse headache (MOH) occurs when acute headache medication is taken on 10 or more days per month for simple analgesics, triptans, or combination products for three or more months, in a person who already has a primary headache disorder. MOH typically presents as a daily or near-daily dull background headache. Treatment involves withdrawing the overused medication — which causes a temporary worsening for one to two weeks before improvement — combined with starting a preventive agent. Naproxen or a short course of prednisolone may help bridge the withdrawal period. Your GP can guide this process; specialist referral is available for complex cases.
What are CGRP therapies and can I access them in Australia?

Calcitonin gene-related peptide (CGRP) therapies are a newer class of migraine-specific treatments. Monoclonal antibodies (fremanezumab, galcanezumab, eptinezumab) given by monthly or quarterly injection or infusion are PBS Authority Required for chronic migraine — defined as 15 or more headache days per month for at least six months — after failure of at least three prior preventive medications. They are specialist-initiated and require documented response at six months. Gepants (rimegepant, atogepant) are TGA-approved but not yet PBS-listed and remain expensive on private prescription. Erenumab is TGA-approved but also not PBS-listed as of mid-2026.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.