A migraine is more than a bad headache. It’s a neurological event with a specific pattern: throbbing or pulsing pain (often on one side of your head), lasting 4 to 72 hours, and accompanied by nausea, vomiting, or intense sensitivity to light and sound. If your headache gets worse when you walk up stairs, bend over, or do other routine physical activity, that’s another strong signal pointing toward migraine.
Not every migraine checks every box, and plenty of people go years without realizing their “bad headaches” are actually migraines. Here’s how to tell the difference.
The Five Features That Point to Migraine
Clinicians use a simple memory aid called POUND to screen for migraine in primary care. Each letter stands for one characteristic feature:
- Pulsatile quality: the pain throbs or pulses rather than pressing or squeezing
- One-day duration: attacks typically last hours to a full day (though they can stretch to three days)
- Unilateral: pain is on one side of the head, not both
- Nausea or vomiting: your stomach is involved, not just your head
- Disabling intensity: the pain is severe enough to stop you from doing normal activities
The more of these features your headache has, the more likely it’s a migraine. You don’t need all five. Having three or four is a strong indicator. If you’re only hitting one or two, a different headache type is more probable.
How Migraine Differs From Tension and Cluster Headaches
A tension headache feels like a tight band squeezing both sides of your head, often across the forehead or wrapping around the back of the skull and neck. The pain is dull and aching, not throbbing. It doesn’t come with nausea, and it rarely stops you from functioning. Most people can push through a tension headache at work or while running errands.
Cluster headaches are a completely different animal. The pain is excruciating and penetrating, centered around or behind one eye. Attacks are shorter than migraines, often 15 minutes to three hours, but they come in clusters: multiple attacks per day for weeks or months, then a long break. The telltale signs are autonomic symptoms on the same side as the pain, like a red or watering eye, a drooping eyelid, nasal congestion, or facial sweating. People with cluster headaches tend to pace or rock during attacks because staying still makes it worse, which is the opposite of migraine, where movement makes the pain worse.
Migraine sits between these two in some ways. The pain is intense and throbbing, usually one-sided, and it comes with a constellation of other symptoms: nausea, vomiting, sensitivity to light and sound. You’ll want to lie down in a dark, quiet room. That instinct to retreat and be still is one of the most reliable clues.
A Migraine Is More Than Head Pain
One reason migraines are underdiagnosed is that the headache phase is only one part of the attack. A full migraine episode can have four distinct phases, and recognizing the ones before and after the pain can help you identify the pattern.
Prodrome (24 to 48 Hours Before Pain)
Up to two days before the headache arrives, your body may send early warning signals. These vary widely from person to person but often include mood changes (irritability, depression, or difficulty concentrating), fatigue, neck and shoulder stiffness, and sensitivity to light and sound. Some symptoms are surprisingly specific to migraine prodrome: excessive yawning, unusual food cravings, and frequent urination. If you notice these same signs reliably showing up a day or two before your headaches, that’s a meaningful clue. In one study, the most common premonitory symptoms were neck stiffness (reported by about 65% of people), light sensitivity (57%), fatigue (53%), and sound sensitivity (50%).
Aura (5 to 60 Minutes Before or During Pain)
About one in four people with migraine experience aura, a set of temporary neurological disturbances that typically start within an hour of the headache. Visual aura is most common: you might see zigzag lines floating across your field of vision, shimmering spots, flashes of light, or blind spots sometimes outlined by geometric shapes. These visual changes usually begin in the center of your vision and spread outward.
Aura can also affect other senses. Some people feel tingling or numbness that starts in one hand and slowly spreads up the arm, or tingling on one side of the face, tongue, or mouth. Others have temporary difficulty finding words or speaking clearly. Aura almost always resolves within 60 minutes, and for most people it follows the same pattern each time.
Postdrome (Hours to a Day After Pain)
After the headache fades, many people experience what’s sometimes called a “migraine hangover.” You might feel exhausted, have body aches, struggle to concentrate, feel dizzy, or remain sensitive to light. This phase can last several hours to a full day and is often the part that surprises people most. If your “recovery day” after a bad headache feels out of proportion to the pain itself, that lingering postdrome is another indicator you’re dealing with migraine.
Tracking Your Headaches Makes Diagnosis Easier
A formal migraine diagnosis requires at least five attacks that fit the pattern. That means keeping a record is one of the most useful things you can do before seeing a doctor. For each headache, note when it started and stopped, where the pain was located, what it felt like (throbbing versus pressing), how severe it was, and any other symptoms like nausea, light sensitivity, or aura. Also jot down what you were doing before it started and whether physical activity made it worse.
You can also gauge how much your headaches are affecting your life using the Migraine Disability Assessment, or MIDAS, which asks about missed days of work, school, and household activities over the past three months. A score of 0 to 5 means little or no disability. Scores of 6 to 10 suggest mild disability, 11 to 20 moderate, and 21 or higher severe. This kind of information helps a clinician understand not just whether your headaches are migraines but how aggressively they need to be treated.
Red Flags That Need Immediate Attention
Most headaches, including migraines, are not dangerous. But certain features suggest something other than a primary headache disorder, and these deserve urgent evaluation.
The most important red flag is sudden onset. A headache that hits maximum intensity within seconds, sometimes called a thunderclap headache, can signal a vascular emergency like a brain aneurysm. This is the kind of headache people describe as the worst of their life, and it needs emergency evaluation.
Other warning signs include: headache accompanied by fever, night sweats, or unexplained weight loss; new neurological symptoms like weakness in an arm or leg, new numbness, or vision changes that don’t fit a typical aura pattern; a brand-new headache pattern starting after age 50; headaches that are clearly getting worse over weeks or months in either severity or frequency; and headaches that change intensity when you shift position (standing to lying down) or that are triggered by coughing or straining. New headaches during or shortly after pregnancy also warrant prompt evaluation for vascular or hormonal causes.
If your headaches follow the same pattern they’ve followed for months or years, that consistency is actually reassuring. It’s the new, different, or rapidly changing headache that raises concern.