Everyday Headaches: Tension-Type, Migraine, and Cluster

The short answer#

Most head pain falls into three primary patterns. Tension-type headache is a dull, pressing ache on both sides, mild to moderate, with no nausea. Migraine is usually one-sided, throbbing, and moderate to severe. It lasts 4 to 72 hours and brings nausea or sensitivity to light and sound. Cluster headache is a brief (15 to 180 minutes), excruciating, strictly one-sided pain around one eye with tearing, a stuffy nostril, and restlessness, striking in bouts. Red flags such as a sudden thunderclap onset, fever with a stiff neck, or a first bad headache after age 50 point to a secondary cause and need prompt evaluation.

Key points#

• Tension-type headache is the most common, affecting roughly 30% of people in a given year. Migraine affects about 15%, and cluster headache about 0.1%.
• The quickest way to separate migraine from tension-type is the company the pain keeps: throbbing, one-sided pain plus nausea or light and sound sensitivity, made worse by routine activity, points to migraine.
• Cluster headache is distinctive once recognized: short, savage, one-sided eye pain with tearing and a blocked nostril, often waking a person at the same hour each night.
• A sudden "worst headache of my life" that peaks within seconds to minutes is a thunderclap headache and a medical emergency until proven otherwise.
• For acute migraine, an anti-inflammatory plus a triptan together outperforms either alone; naproxen with sumatriptan leaves about 1 in 4 people pain-free at two hours.
• High-flow oxygen and injectable sumatriptan are the fastest, best-evidenced treatments for an active cluster attack.
• Using acute painkillers on too many days per month can turn episodic headaches into a daily pattern known as medication-overuse headache.

What are the different types of headache?#

Doctors split headaches into two big buckets. Primary headaches are the disorder themselves, with no other disease driving them, and they account for the large majority of cases. Secondary headaches are a symptom of something else, from a sinus infection to bleeding around the brain. The three primary patterns worth knowing are tension-type, migraine, and cluster.

Tension-type headache is the plain, workhorse headache almost everyone gets. It feels like a tight band or pressure across the forehead or back of the head, on both sides, and it rarely stops you from functioning. Stress, poor sleep, eye strain, and long hours at a screen commonly set it off. Sleep quality matters more than people expect, and our piece on brain, aging, and sleep health covers why rest is one of the most underrated headache levers.

Migraine is a neurological condition, not just a bad headache. Attacks come in stages and can include a warning phase, an aura in some people (visual zigzags, blind spots, or tingling that spreads over minutes), the headache itself, and a washed-out recovery day. The pain is often one-sided and pulsating, and everyday movement like climbing stairs makes it worse.

Cluster headache is the rarest of the three and among the most severe pains in medicine. Attacks are strictly one-sided, centered on or behind one eye, and come in "clusters," bouts of weeks to months separated by long pain-free stretches. Attacks often follow a clock, hitting at the same time of day or waking a person a few hours into sleep, and they can recur at the same season year after year.

How do I know if it is a migraine or a tension headache?#

Look at four things: where the pain sits, how it feels, what comes with it, and how activity changes it. Migraine tends to be one-sided, throbbing, and worse when you move, and it drags along nausea or a strong dislike of light and sound. Tension-type is bilateral, pressing rather than pulsing, and it does not care much whether you sit still or walk around. A simple memory aid for migraine is POUND: Pulsating quality, One-day duration (4 to 72 hours), Unilateral, Nausea, and Disabling intensity. The more of these that fit, the more likely the diagnosis is migraine.

In practice the two overlap. Many people who get frequent headaches have both, and a mild migraine can masquerade as tension-type. The presence of nausea, one-sidedness, or clear worsening with activity tilts the odds toward migraine. Cluster rarely gets confused with the other two because of its short duration, extreme intensity, and the tearing, congested eye on the painful side.

When is a headache dangerous?#

Most headaches are benign, but a short list of features suggests a secondary cause that needs a workup. Clinicians use the SNNOOP10 checklist, and the individual items matter more than the acronym:

• Systemic signs such as fever, weight loss, or night sweats
• Neoplasm history (a known or past cancer)
• Neurologic deficit: weakness, numbness, trouble speaking, double vision, or confusion
• Onset that is sudden and severe (thunderclap), peaking in seconds to minutes
• Older age, meaning a first significant headache after 50
• Pattern change: a headache that is new, different, or steadily escalating
• Positional pain that clearly worsens lying down or standing up
• Precipitated by coughing, sneezing, straining, or exertion
• Papilledema (swelling at the back of the eye)
• Pregnancy or the weeks after delivery, a painful red eye, head trauma, a weakened immune system, or heavy painkiller use

The single most urgent pattern is the thunderclap headache. A head pain that slams to maximum intensity almost instantly can signal bleeding around the brain (subarachnoid hemorrhage) and warrants emergency imaging, usually a non-contrast CT scan performed within the first several hours, when it is most sensitive. Fever with a stiff neck and light sensitivity raises concern for meningitis. A new, progressive headache in someone over 50 with jaw pain or scalp tenderness can point to giant cell arteritis, which threatens vision and needs same-day attention.

What does each headache type respond to?#

Matching the treatment to the pattern is where a correct label pays off.

Tension-type headache usually responds to simple over-the-counter analgesics such as ibuprofen, naproxen, aspirin, or acetaminophen. For frequent or chronic tension-type headache, a low nightly dose of amitriptyline is the best-supported preventive. That sits alongside attention to sleep, stress, and posture.

Migraine has a wider toolkit. For mild to moderate attacks, anti-inflammatory drugs and acetaminophen are first-line. For moderate to severe attacks, triptans (such as sumatriptan or rizatriptan) are first-line, and the combination of a triptan with an anti-inflammatory works better than either alone. Naproxen paired with sumatriptan leaves roughly 1 in 4 people pain-free at two hours, better than either drug alone. Newer options, the gepants (rimegepant, ubrogepant, zavegepant), help people who cannot use triptans because of heart or vascular risk, since they lack the blood-vessel cautions that come with triptans and ergots. For prevention, longstanding choices include topiramate, propranolol, amitriptyline, and candesartan, and the CGRP-targeting drugs (the injectable antibodies erenumab, fremanezumab, galcanezumab, and eptinezumab, plus the oral gepants atogepant and rimegepant) are now used as a first-line preventive rather than a last resort. For the biology behind these drugs, see our explainers on how CGRP drives migraine, from mechanism to medicine, and why CGRP drugs became first line for migraine prevention. Two classes to avoid for routine migraine are opioids and butalbital-containing combinations, which work poorly and worsen the long-term course.

Cluster headache needs fast, specific treatment because attacks are short and brutal. The two acute treatments with the strongest evidence are high-flow 100% oxygen (delivered at 12 liters per minute or more through a non-rebreather mask for about 15 minutes) and injectable sumatriptan under the skin; zolmitriptan nasal spray is another option. Oral tablets act too slowly to help. To suppress a bout, verapamil is the mainstay preventive, often started with a short course of corticosteroids or a greater occipital nerve block to bridge the gap while it takes effect.

One caution cuts across all three types. Reaching for acute painkillers or triptans on too many days each month can backfire and produce medication-overuse headache, a rebound pattern of near-daily pain. Tracking how many days per month you take any acute medication is one of the simplest ways to keep headaches from escalating.

When to seek care#

Call emergency services or go to an emergency department for a headache that:

• Comes on like a thunderclap, reaching its worst within seconds to a minute
• Comes with fever and a stiff neck, or with a spreading rash
• Brings weakness, numbness, slurred speech, vision loss, or confusion
• Follows a head injury, especially with drowsiness or repeated vomiting
• Starts during pregnancy or soon after delivery and is severe or unusual

Arrange a prompt (non-emergency) visit for a first bad headache after age 50, a headache that keeps worsening over days to weeks, a clear change in your usual pattern, headaches that wake you from sleep, or acute-medication use creeping past a couple of days each week. Cluster-pattern attacks with a tearing, congested eye also deserve a neurology referral, because the right acute treatment changes the experience dramatically.

For a headache that worries you or does not fit your usual pattern, please talk with a licensed clinician who can evaluate your specific situation.