Migraine is not just a bad headache: what the difference is and why it matters

“I get headaches too sometimes. I just take a tablet and get on with it.”

Almost everyone with migraine has heard this sentence. A colleague says it when someone stays home for the second time in a month. A mother-in-law says it when Sunday lunch is cancelled. Sometimes people say it to themselves, at six in the morning, lying in a dark room and wondering whether they truly can’t manage or are just “giving in”. And every time it is said, a small injustice happens: an illness with its own name, its own criteria and its own mechanisms in the brain is shrunk down to “a slightly worse headache”.

In this post I want to explain why migraine is not simply a stronger version of an ordinary headache, how the two differ, and why the difference matters — for treatment, for relationships, and for the way a person with migraine talks to themselves. Let me say at the outset what you won’t find here: a diagnosis or medication recommendations. Those belong with your doctor and neurologist. My contribution lies elsewhere — with stress, anxiety, relationships and everything that happens to a person when pain takes over their calendar every few weeks.

Migraine is a neurological disease, not a psychosomatic symptom

I want to state this very clearly, because a psychotherapist writing about migraine can easily be misunderstood. Migraine is not a psychosomatic disorder. It is not “stress that has moved into your head”, it is not a sign of suppressed emotions, and it is not something that would disappear if you just relaxed a little more. It is a neurological disease with a strong hereditary component: it often runs in families, it is linked to the way the brain processes sensory input, and specific pathways are involved in an attack — the trigeminal nerve, the brainstem, the hypothalamus and signalling molecules such as CGRP, which some newer medicines also target.

A review by Goadsby and colleagues describes migraine as a disorder of sensory processing. Put simply, the brain of a person with migraine is tuned differently: it responds more sensitively to light, sound, smell and changes in rhythm, and this sensitivity fluctuates through a cycle that the attack merely completes.

So why am I writing about migraine at all? Because an illness that is not psychological in origin has psychological consequences — and some psychological circumstances influence how often and how severely it shows itself. Stress, poor sleep, anxiety and depression are closely intertwined with migraine. Not as the cause, but as part of a loop. I wrote about how different things are with physical symptoms that have no clear physical basis in “The tests are normal, but it still hurts”: what therapy knows about psychosomatics. Migraine does not belong in that group, and the distinction matters.

How many people it affects

Migraine is one of the most common diseases in the world. It is estimated that roughly one adult in seven has it, and women two to three times more often than men. An analysis of the 2019 Global Burden of Disease study showed that migraine is the second leading cause of years lived with disability worldwide — and the first among women under fifty. These are not years lost to death, but years in which people are alive yet unable to work, care for their children or be with friends the way they would like.

That figure stops me every time. This is an illness that hits hardest in exactly the years when people are building a career, a relationship and a family. And it is an illness that is invisible from the outside: between attacks a person looks perfectly healthy, so those around them find it hard to believe how bad last Wednesday was.

How migraine differs from tension-type headache

The most common headache in the world is not migraine but tension-type headache — that dull, squeezing feeling around the head, as if you were wearing a hat that is too tight. The International Classification of Headache Disorders (ICHD-3), which doctors work from, describes both with clear criteria. I am not a doctor and I don’t make diagnoses, but knowing the difference helps people describe more accurately what is happening to them.

Migraine without aura typically means that an attack lasts between four and seventy-two hours if untreated, and that the pain has at least two of these features: it is one-sided, throbbing, moderate to severe, and it gets worse with ordinary physical activity, such as climbing stairs. On top of that it comes with nausea or vomiting, or with sensitivity to both light and sound. Tension-type headache is usually on both sides, pressing, mild to moderate, does not worsen with movement and does not cause nausea.

In roughly a quarter to a third of people with migraine, an aura appears before or during the attack: usually visual disturbances, zigzag lines, shimmering spots or a gap in part of the visual field, sometimes tingling or difficulty finding words. Aura symptoms develop gradually and each lasts between five and sixty minutes. What happens in the brain during that time is a topic of its own.

The difference is not only in intensity. Migraine is an attack with a whole range of phenomena that can begin the day before — yawning, tiredness, irritability, craving particular foods — and that don’t end when the pain eases. I described how these phases follow one another in more detail in The phases of a migraine attack: what happens from the first signs to the end.

When it’s not time to think, but time to call 112

Before I go on, there is one section I must not leave out. Most headaches are primary — they are the illness itself, with no other disease behind them. Rarely, however, a headache is a sign of something else that needs urgent help. Doctors have lists of warning signs for this. With any of these, call 112 straight away (the emergency number in Slovenia and across the EU):

• a sudden, extremely severe headache that peaks within seconds or a minute — “the worst headache of my life”;
• a headache with paralysis or weakness on one side of the body, a drooping corner of the mouth, slurred speech, confusion or loss of consciousness;
• a headache with fever and a stiff neck, possibly with a rash;
• a headache after a blow to the head, especially if drowsiness, vomiting or confusion follow;
• a headache with an epileptic seizure.

With these signs, see a doctor as soon as possible, the same or the next day: a headache that is new after the age of fifty; a headache that is different from your usual ones or escalates week by week; a headache that wakes you or worsens when you cough, sneeze or strain; an aura that appears for the first time, lasts more than an hour or is always on the same side; a new headache in pregnancy or after giving birth; a headache in someone with cancer or a weakened immune system.

Even someone who has had migraine for twenty years can get a different kind of headache. “It’s just my migraine” is a sentence worth checking every time something is not the way it usually is.

Why the difference matters

You could say: it hurts either way, the name doesn’t matter. But it does, for at least three reasons.

First, because of treatment. Migraine is treated differently from tension-type headache. There are medicines designed specifically for a migraine attack and medicines that prevent attacks. Someone who thinks they have “just headaches” often reaches for whatever is in the bathroom cabinet for years and never finds out that something could help them more. Frequent use of painkillers can, over time, cause headaches in itself. Which medicine, when and how much is a question for your doctor — not for a blog, a forum or the neighbour.

Second, because of understanding yourself. When people learn that they have a neurological disease with known mechanisms, something often loosens. They are not lazy, not oversensitive, not “making it up”. They have a brain that responds to certain circumstances with an attack. That does not remove responsibility for looking after yourself, but it does remove shame.

Third, because of the people around you. A study by Young and colleagues found that people with chronic migraine experience stigma comparable to, or even greater than, that of other chronic neurological conditions. Stigma does not come only from others. People often take it in and start saying to themselves the sentences they have heard: that they exaggerate, that they should push through, that others manage.

What happens in the mind when we think about pain

This is where my field begins. Pain is not just a signal from the body but also an experience that the brain puts together from the signal, expectation, attention and emotion. This doesn’t mean the pain is “in your head” in the everyday sense. It means that how we experience it and how much it limits us are also shaped by thoughts and mood. There is more on this in the explanation of pain and emotion.

With migraine, a particular pattern often develops. Because an attack comes unpredictably and is severe, people learn to monitor their body constantly: is this the start? Is that slight heaviness behind my eyes a sign? This vigilance is understandable, but it can become a burden in its own right. The thought “it’s going to start again and I won’t cope” triggers tension, tension disturbs sleep, and for many people poor sleep is one of the factors that make an attack more likely. The loop closes, even though none of these thoughts caused the migraine.

This way of thinking, when the mind quickly spins towards the worst possible outcome, has a name: catastrophising. In pain it is well researched and linked to greater disability, though not necessarily to a stronger signal from the body. If this kind of thinking follows you outside migraine too, you may find A single thought can ruin your whole day — if you believe it helpful.

A conversation that repeats itself

This is how a conversation between partners might sound when migraine moves into the house for a while (composed, not a real person):

“You’re not coming with us again? You looked completely fine yesterday.”
“I was fine yesterday. Today I can’t see properly out of my left eye and I know what comes next.”
“Can’t you take something and come for at least an hour?”
“I can come and sit there with a face like someone’s got me in a vice. Would you prefer that?”
“I don’t know. I’m just tired of cancelling.”
“So am I. More than you.”

There are two truths in this short exchange. The partner who is tired of cancelling is not being cruel. And the person with migraine who is defending herself is not exaggerating. Both are losing something, and neither of them chose the illness. When the conversation turns into “you don’t believe me” versus “you always cancel”, migraine is no longer just one person’s illness but a third presence in the relationship. In relational family therapy, which I am training in, this is exactly the space we are interested in: the space between people, and how both can name their loss without accusing each other.

Where psychological work can help

Psychological approaches do not cure migraine and do not replace medication. But they can be an important part of the whole. The best researched are relaxation techniques, biofeedback and cognitive behavioural approaches. A randomised trial by Holroyd and colleagues, published in the BMJ, showed that for people with frequent migraines, combining a preventive medicine with a behavioural migraine management programme brought more benefit than either approach on its own. The behavioural part was not “calm down”, but systematic learning: recognising patterns, relaxation, handling stress and acting in time when an attack begins.

One of the simplest evidence-based techniques is progressive muscle relaxation, in which you tense and release groups of muscles in turn. It doesn’t work overnight; the effect shows with regular practice over weeks. Which techniques have the strongest basis in migraine is described in more detail in What helps with migraine besides medication: relaxation techniques with evidence.

In therapy with people who have migraine, we often don’t work directly with the pain but with what gathers around it: guilt at having cancelled again; anxiety about the next attack; anger that the body won’t cooperate; relationships that have grown tired. Migraine often goes hand in hand with anxiety and depression, and these need their own attention. I described how mood shows in the body in Depression and the body: pain, fatigue and digestion.

Exercise: describe your headache before you describe it to a doctor

At an appointment people often just say “my head hurts badly”. A precise description is far more useful to a doctor. At the same time, this exercise changes your relationship with the pain: instead of simply being swept away by it, you observe it for a few minutes. You can start today.

1. Choose one notebook or one note on your phone that is only for this. Don’t mix it with other notes.
2. With every headache, write down four things: when it began and ended, where it hurt (one side, both, behind the eye), what the pain was like (throbbing, pressing, stabbing) and what came with it (nausea, light, sound, visual disturbances).
3. Write down what you did and how much it helped — including any medicine you took, and the time. This is information for your doctor, not a judgement of you.
4. Add one line about the day before: how you slept, whether you were under pressure, whether anything changed in your routine. You’re not looking for a culprit but for a pattern.
5. After four weeks, read it all at once and take your notes to the doctor. If you notice that the tracking is making you more anxious, write in less detail — the basics are enough.

If you’d like a simpler format, the knowledge base also has a diary of bodily signs that you can adapt.

Where my argument stops

This whole post says that migraine is not just a bad headache. But it is only fair to say the reverse too: not every bad headache is migraine. Once people learn the word, they sometimes use it for everything that hurts. A severe tension-type headache, a headache from overusing medication, a headache with sinusitis or a headache as a sign of another illness are different things and need different help. Self-diagnosis after reading an article — including this one — is not a diagnosis.

The second limit: when I stress that migraine is not psychological, that does not mean psychological factors play no role at all. With tension-type headache the link with stress and muscle tension is even closer, and psychological work often carries more weight there. With migraine, psychological approaches can help with how often and how severe attacks are, and with how a person bears them — but they don’t remove the cause.

And the third: you don’t necessarily need therapy. Many people with migraine live full lives with good cooperation with their doctor, a few regular habits and understanding people around them. Therapy comes into its own when migraine starts shaping your relationships, when fear of an attack keeps you at home even when there isn’t one, or when anxiety or low mood that won’t lift appear alongside the pain.

When you hear “it’s just a headache”

Let’s return to the sentence from the beginning. You can’t control what people say. But you can choose what you answer — and above all what you say to yourself. Some people find it helps to have a short, calm sentence ready: “Migraine is a neurological disease. I’m having an attack today; tomorrow will probably be better.” You don’t have to explain everything, and you don’t have to apologise.

The inner sentence matters more. If you have been telling yourself for years that you exaggerate, it’s worth noticing whose voice that is. Often it isn’t yours. And often it can slowly be replaced by a voice that is more accurate: “I have an illness with its own rules. I look after myself as well as I can. Some days I won’t have under control, and that is not my fault.”

What to remember

• Migraine is a neurological disease with a hereditary component, not a psychosomatic symptom and not “just a bad headache”.
• It differs from tension-type headache in the type of pain, the accompanying signs and its course; diagnosis and treatment are decided by a doctor or neurologist.
• A sudden worst headache of your life, weakness on one side, speech problems, fever with a stiff neck or a headache after a blow to the head mean calling 112 at once.
• Psychological approaches — relaxation, cognitive behavioural work, handling stress — don’t cure migraine, but they can reduce its impact on your life.
• Shame and guilt are not part of the illness; they come from the way we talk about it.