Mixed Tension Migraine: Things You Need to Know

Both migraine and tension headaches can be painful, exhausting, and unpleasant. According to the American Migraine Foundation, around 39 million Americans¹ live with migraines. Meanwhile, at least two out of three adults in the US suffer from tension headaches.

A mixed-tension migraine combines the symptoms of these two conditions. In some cases, a migraine can come first and trigger tension headache symptoms. In others, stress caused by the tension headache triggers a migraine.

While it’s not always possible to prevent a mixed-tension migraine, management strategies and treatment options may help improve your quality of life.

Let’s take a closer look at mixed-tension migraines.

What is a mixed-tension migraine?

A mixed-tension migraine is a condition that combines the symptoms of a migraine and tension headache.

While the underlying cause of migraines is currently unknown, some scientists believe they occur due to neuron impairment.² Others blame the narrowing of the blood vessels.

Meanwhile, tension headaches occur when the back, neck, and scalp muscles tighten. This could happen due to stress or sleep problems.

The intensity of mixed tension symptoms can vary from person to person. For some, more of these symptoms are migraine-related, while others mainly have tension headache symptoms.

Today, the International Headache Society doesn’t recognize mixed tension migraine as an official migraine type. However, migraine and tension-type headaches may be considered related conditions with shared environmental and lifestyle factors.

Migraines versus tension headaches

Distinguishing a migraine from a tension headache may be challenging, but they have key differences. These include:

Aura

Migraines are usually preceded by an aura. However, you can get migraines without aura.

Aura affects your sight (blind spots, seeing flashing lights) and usually lasts from five minutes to an hour.

Symptoms

While some symptoms of migraine and tension headaches overlap (for example, throbbing aches and neck stiffness), tension headaches don’t usually cause nausea, sensitivity to light, or vomiting.

The pain during tension headaches is usually distracting, not debilitating.

Duration

Tension headaches don’t usually last more than several hours (however, some may last for months). Meanwhile, migraine attacks could last for up to 72 hours.

When it comes to mixed tension migraines, you might experience a mix of symptoms. However, an aura is highly unlikely. The duration of this condition varies from person to person.

Causes of a mixed tension migraine 

Mixed tension migraines are caused by the same things as migraines and tension headaches.

Migraine causes

Researchers are yet to establish what causes migraines. Initially, they believed migraines were related to the blood vessels. However, the latest theory³ states migraines could stem from certain problems with neurons and changes in the brain structure.

Tension headache causes

Similar to migraines, the exact mechanism that causes these headaches is yet to be confirmed.

Tension headaches usually occur as a reaction to specific triggers. However, these headaches are most likely multifactorial and depend on increased sensitivity to pain signals from the body (nociception) in the central nervous system.

While more research needs to be done, it is thought that some people have a genetic predisposition to both conditions.

If someone in your immediate family suffers from migraines, tension headaches, or mixed tension headaches, you are more likely to develop these conditions. However, in contrast with migraines, genetics play less of a role in tension-type headaches (if any).

Triggers 

Mixed tension migraine triggers include:

• Activities that force you to hold your head in the same position for a long time (a desk job, for example)

• Sleeping in a cold room with your neck in an abnormal position

• Stress (physical and emotional)*

• Alcohol use*

• Too much caffeine* or caffeine withdrawal

• Sinus infection

• Jaw clenching and teeth grinding*

• Excessive eye strain

• Smoking

• Strenuous activities*

• Changes to your sleep schedule

• Hormones

• Weather change

• Certain foods

• Dehydration

• Natural or bright light

• Certain smells

• Certain medications

• Missing meals

• Lower socioeconomic status

• Somatization (a condition where psychological issues are exhibited as physical symptoms with no organic cause)

*Trigger for both migraine and tension-type headache.

When a migraine starts, you might feel stressed. This stress could trigger a tension headache. Meanwhile, stress or sleeping issues that stem from a tension headache could trigger a migraine.

Mixed tension migraine symptoms 

Symptoms differ from person to person. They are a combination of migraine and tension headache symptoms. You could have more tension headache symptoms and fewer migraine symptoms or vice versa.

Mixed tension migraine symptoms include:

• Pain on both sides of your head

• Dull pain that feels like a band around your head

• Pain that affects the back of your head or neck

• Pulsing or pounding pain

• Sensitivity to light, noise, or odors

• Nausea and vomiting

• Watering eyes

• Nasal congestion

• Feeling pressure in your face

These symptoms will likely worsen if you don’t eliminate the triggers, such as bright lights or strenuous activities.

A mixed tension migraine could be mild and last for under an hour, but some people get severe symptoms for days. In this case, your mixed tension migraine could become debilitating.

You may find it tricky to identify a mixed tension headache. You might not be able to tell it apart from a migraine without aura or a severe tension headache. A medical professional can help you with this.

How to diagnose mixed tension migraine

While migraines and headaches are prevalent, only around 5%⁴ of people who suffer from them seek professional medical advice.

If you develop the symptoms above, speak to your doctor. A medical professional can diagnose the condition and suggest treatment and prevention techniques.

The following approaches can lead to a diagnosis:

• Gathering your personal and family medical history

• Neurological exam

• Computerized tomography (CT) and magnetic resonance imaging (MRI) scans

• Eye exam

• Blood tests

• Spinal tap

Gathering your personal and family medical history 

During the initial consultation, your doctor will ask you to describe your symptoms and share a history of mixed tension migraine attacks. They will then check your symptoms against diagnostic criteria.

To better understand your condition, the doctor may ask you to keep a migraine journal. This can help you identify how often you have symptoms, what triggers your condition, and which medications (if you’ve been taking any) help.

Your doctor will also review your medical history and ask if there is a history of headaches and migraines in your family.

It would help if you could start keeping a headache diary before going to the doctor or at least write down everything you remember about them.

Neurological exam 

To rule out serious conditions that might be causing your mixed tension migraines — like tumors, meningitis, fluid in the brain, or bleeding in the brain — your doctor may conduct a neurological exam.

During the exam, a medical professional will check:

• Your level of awareness and interaction with the environment

• Reflexes

• Motor function

• Balance

• Sensory reactions

• Coordination

This exam evaluates how your nervous system works. It does not typically cause pain or severe discomfort. The extent of this exam may depend on the type and severity of your symptoms.

CT and MRI scans 

Like neurological exams, the following tests can help your doctor determine if your mixed tension migraine has a serious cause.

• MRI — using a magnetic field and radio waves to see images of your brain and blood vessels

• CT — using a series of x-rays to get detailed images of the brain

These scans help rule out tumors, brain bleeds, strokes, infections, and neurological conditions.

Your doctor may order a sinus x-ray if they believe a sinus infection causes your symptoms. While CT and MRI scans are more informational, a sinus x-ray is faster than an MRI and uses less radiation than a CT scan.

Eye exam

Your doctor may refer you to an ophthalmologist (eye doctor) if you are experiencing eye pressure symptoms. They can perform an eye exam and a pressure test to rule out optic nerve pressure or glaucoma.

Blood tests

A doctor will likely order blood tests to rule out medical conditions that could be causing your headaches, such as diabetes and thyroid issues. They may also order a urine test.

Spinal tap

If your doctor suspects you have a spinal headache, they may suggest a spinal tap (also called a lumbar puncture).

A spinal headache occurs when the liquid around your brain and spinal cord (cerebrospinal fluid) leaks out of the surrounding tissues. When this happens, the tissues in your brain can stretch and cause pain.

During a spinal tap, a doctor will insert a needle into your spinal cord to collect cerebrospinal fluid for analysis. The procedure is carried out under local anesthetic, and you may have it as an outpatient.

If your doctor finds any underlying conditions, your treatment will start by addressing them.

How to treat a mixed tension migraine

The tests you undergo may reveal no underlying condition causing your mixed tension migraines. In this case, your doctor will recommend a treatment that addresses migraines and tension headaches.

Pain relief 

Pain is usually the strongest symptom of a mixed tension migraine. You can take over-the-counter medications, such as ibuprofen (Motril or Advil) or aspirin to manage your pain. Medications that combine caffeine, aspirin, and acetaminophen (such as Excedrin Migraine) may also be useful.

Sometimes, your doctor may prescribe stronger medication to relieve your pain. However, long-term use of pain-relieving medications (both prescription and over-the-counter) could lead to dependence, addiction, withdrawal effects, side effects, and hospital admission.

Prescription medication 

Your doctor may also prescribe medication typically taken to improve migraine symptoms, including:

• Ergot alkaloids, like dihydroergotamine nasal spray (Migranal or Trudhesa) or injection (DHE-45): has a similar mechanism to triptans and provides some relief when taken shortly after symptoms begin.

• Triptans, like naratriptan (Amerge) and sumatriptan (Imitrex): medications available in different forms that work by blocking pain pathways in your brain.

• Lasmiditan (Reyvow): a selective serotonin receptor agonist that has been found to effectively treat migraine⁵ with or without aura

• CGRP antagonists, like ubrogepant (Ubrelvy): these drugs work by blocking a chemical in your brain that mediates pain transmission of migraines. They are prescribed to treat migraine symptoms with or without aura.

These drugs can cause side effects, so discuss them with your doctor before starting your treatment.

Nutrition and complementary therapies 

Studies show taking certain supplements may reduce migraine frequency and benefit migraine management. These supplements include:

• Riboflavin (B2)

• Co-enzyme Q10

• Magnesium

Consult your doctor before taking any supplements. Overdosing on vitamins can have serious side effects.

To help ease mixed tension headache symptoms, you can try migraine-relieving home remedies such as:

• Acupressure⁶

• Essential oils⁷

• Relaxation techniques

• Massage

• Yoga⁸

Don’t push yourself to do regular chores or participate in activities when you have a headache. This can worsen your symptoms. Allow yourself to rest in a cool, quiet, and dark environment.

Cognitive behavioral therapy 

Cognitive behavioral therapy (CBT) involves sessions with a therapist. During these sessions, you can learn how to control your stress, cope with pain, and replace negative feelings with positive ones.

Stress is one of the most common triggers⁹ of tension headaches (we can assume this is also true for mixed tension migraines). Learning how to deal with stress can prevent an attack or help reduce the risk of your symptoms worsening.

Can you prevent a mixed-tension migraine?

You may not be able to prevent all mixed tension migraines, but taking the following preventive measures may help:

• Sticking to a regular sleeping schedule

• Exercising for at least 30 minutes a day

• Eating regular meals (don’t skip meals)

• Take preventive medications as recommended by your doctor

• Sleeping in a comfortable environment

• Take active breaks from your desk job to relax your head and neck muscles

If you keep a mixed tension migraine journal, you may already know your common triggers. Avoiding your triggers can help prevent a mixed-tension migraine.

Preventive medications

Your doctor can also prescribe preventive medications for migraines, including:

• Beta-blockers

• Antidepressants

• Anti-seizure drugs

• Botox injections

• CGRP monoclonal antibodies

The lowdown 

A mixed-tension migraine combines the symptoms of tension headaches and migraines. The key to treating these migraines is diagnosing them correctly and following your doctor’s advice closely.

Learning how to prevent, manage, and treat mixed-tension headaches may help improve your quality of life. Contact your doctor as soon as you experience mixed tension migraine symptoms.