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Acta Medica Mediterranea, 2015, 31: 615
ASSESSMENT OF ANXIETY, DEPRESSIVE DISORDERS AND PAIN INTENSITY IN MIGRAINE AND
TENSION HEADACHE PATIENTS
F RANCESCO C ORALLO 1, M ARIA C RISTINA D E C OLA 1, V IVIANA L O B UONO 1, R OSARIO G RUGNO 1, G IUSY P INTABONA 3,
RICCARDO LO PRESTI1, PLACIDO BRAMANTI1, SILVIA MARINO1,2
1
IRCCS Centro Neurolesi “BoninoPulejo”, Messina - 2Department of Biomedical Sciences and Morphological and Functional
Imaging, University of Messina, Messina - 3Faculty of Medicine and Surgery, University of Messina, Messina, Italy
ABSTRACT
Introduction: Headache is one of the most common chronic disease affecting around 152 millions of people in Europe, with a
man: woman ratio of 1:3. Recent studies show that headache causes significant limitations in daily life with effects on emotional-behavioural and relational aspects. In particular the migraine headache, whose onset is often at a young age, that is the phase of maximum
working, social and familiar activity. The aims of this study were to investigate the relationship between migraine-related disability
and the presence of anxiety and depression in order to assess how the disability affects the patient activities.
Materials and methods: We enrolled 123 migraine patients. All information related to headache was collected by means of
interviews, examination of medical records, psychometric tests for measuring anxiety, depression and disability scale. Demographic
and clinical characteristics, such as gender, age, education, pain intensity, and frequency of headache were also collected.
Results: There was a significant difference in Hamilton Rating Scale for Anxiety and Hamilton Rating Scale for Depression scores between patients who declared to suffer from headache until 10 days per trimester, and patients who declared more than 10 days (p
< 0.05 in both cases). Logistic regression analysis identified gender, age and migraine frequency as feasible risk factors; the migraine
intensity was not significant (p = 0.96), as well as the diagnostic category (p = 0.3). Especially moderate headache frequency and
female gender were the highest risk factors for a co-morbidity of anxiety and depressive disorders and pain intensity.
Conclusion: Migraine condition may involve the onset of a severe disability. Indeed, independently from the diagnostic category, an high degree of disability is often related to the presence of anxious and depressive symptoms.
Key words: anxiety, depression, disability, migraine, co-morbidity.
Received June 18, 2014; Accepted April 02, 2015
Introduction
Headache is a very common and debilitating
disease that causes significant limitations in daily
life with effects on emotional-behavioural and relational aspects. Such disease affects around 152
millions of people in Europe, of whom 15 millions
are Italian (1). The International Classification of
Headache Disorders (ICHD) includes among the
primary headache the tension-type headache and
migraine. The tension-type headache slowly rises
and causes an oppressive pain: it can be episodic or
chronic. Migraine, instead, is a chronic disease
with episodic manifestations that can increase in
frequency over the years. Among the different
headache forms, migraine has a high prevalence
and social impact. It is characterized by throbbing
pain generally in one side of the head, often associated to nausea, phono-and photophobia, such as to
significantly compromise the patient’s efficiency.
Indeed, the onset of the migraine is often at a
young age, that is the phase of maximum working,
social and familiar activity. Usually, migraine is
divided in migraine with and without aura(2,3).
616
The chronic headache worsens daily living
activities, precludes the possibility of leisure and a
normal social life, compromises even the psychological well-being. Headache seems to be a gender’s disease, with a man: woman ratio of 1:3. In
Italy, the percentage of adult population affected
by any form of headache is 46%. In particular, 11%
for migraine, 42% for tension-type headache, and
3% for chronic daily headache. In western countries, the prevalence of migraine in the general
population is equal to 10-12% (6-12% amongst
males and 15-18% amongst females). 25% of
migraine sufferers have their first attack in the preschool age (4). Biochemical markers, neurophysiological or other predictive indicator of chronicity
are not well-known. However, Radat et al. identified psychiatric co-morbidity as an important factor for the development of chronic headache (5).
Many studies have revealed a relationship between
migraine or headache and psychopathology (6,7).
Murat et al., by using a Structured Clinic Interview
(SCID-I), found anxiety-depressive disorders in
migraineurs as well as in tension-type headache
patients(8,9,10). Nevertheless, migraine appeared primarily associated with anxiety disorders and panic
attacks, whereas studies on tension type headache
revealed the presence of both depression and anxiety(11). A significant increase of depression prevalence in both chronic headache and migraine has
been detected, especially in females(12,13). Although
the evidence to show the association between
headache and mood disorder, has not been proved
the correlation of specific headache characteristics
with depression and anxiety(11).
Our aim is to assess the relationship between
related headache disability, intensity of perceived
pain and emotional disorders, focusing on the
effects that these variables have on daily living
activities(14,15). In particular, we evaluated the differences in the presence-absence of anxiety and
depressive symptoms in patients with and without
aura migraine and chronic and tension-type
headache.
Materials and methods
One hundred and twenty-three subjects with
tension-type headache and migraine episodes were
consecutively recruited. Eight patients were
excluded because of missing administration of the
Migraine Disability Assessment (MIDAS) questionnaire(16). Thus, the study sample consisted of
Francesco Corallo, Maria Cristina De Cola et Al
115 subjects with mean age of 43.5 ± 16.5 years,
and mean education of 11.5 ± 4.4 years.
According to ICHD-II we divided the patients
in a) migraine with aura; b) migraine without aura;
c) chronic migraine; d) tension-type headache. The
patients had a clinic diagnosis for at least six
months.
The study protocol was approved by the Local
Ethics Committee according to the 1964
Declaration of Helsinki and its later amendments.
All patients gave written consent to the study and
minor subject consents were signed by legal
guardians. All information related to headache was
collected by means of interviews, examination of
medical records, psychometric tests for measuring
anxiety, depression and disability scale.
Demographic and clinical characteristics, such as
gender, age, education, pain intensity, and frequency of headache were also collected.
Headache pain intensity was assessed by an
11-point pain scale (0 indicating no headache and
10 severe headache). The MIDAS questionnaire
was used to assess disability related to headache
during daily activities (work, home and family
commitments, leisure or social activities). The
migraine disability was graded in four classes
according to MIDAS scores: 0-5 as minimal, 8-10
as mild, 11-20 as moderate, and 21 or more as
severe disability.
Hamilton Rating Scale for depression (HAMD) and Hamilton Rating Scale for anxiety (HAMA) were used to asses anxiety and depressive disorders (17). Patients did not undergo specific treatment(neither pharmacological nor psychological)
for anxiety or depression.
Statistical analysis
We considered both raw scores and the following dichotomous variables: (i) presence of anxiety or depression symptoms, when the person had
a score greater than 8 in at least one between
HAM-A and HAM-D; (ii) occurrence of only anxiety symptoms when the person had HAM-A ≥ 8
and HAM-D < 8; (iii) occurrence of only depressive symptoms when the person had HAM-A < 8
and HAM-D ≥ 8; (iv) occurrence of co morbid
symptoms when the person had HAM-A ≥ 8 and
HAM-D ≥ 8.Non-parametric analysis was performed because the Anderson-Darling test results
and the graphical exploration of the data by means
of box-plots indicated that the target variables were
non-normal distributed. Continuous variables were
Assessment of anxiety, depressive disorders and pain intensity in migraine and tension headache patients
617
expressed in mean ± standard deviation or in medivalue around 10 days in both genders, as showed in
an ± first-third quartile, as appropriate, whereas
Table 1. The mean pain intensity measured by a 11categorical variables in frequencies and percentpoint pain scale (0-10) was 7.1 ± 1.97.
ages. Correlations between variables
Migraine
Migraine
Migraine
Migraine
Migraine
Chronic
Tension
Disability
frequency
intensity
with aura
without aura
migraine
headache
were computed by Spearman’s coefficient, or by point-biserial correlation Female 14.5 (4.7 - 21.0) 10.0 (6.0 - 40.0) 7.5 (6.0 - 8.0) 7 (6.08) 24 (20.87) 32 (27.84) 21 (18.26)
coefficient when one variable was Male 10.0 (4.0 - 21.0) 10.0 (7.0 - 20.0) 7.0 (4.0 - 8.0) 5 (4.35)
5 (4.35)
7 (6.08)
14 (12.17)
dichotomous. The X2 test, the MannAll
13.0 (4.0 - 21.0) 10.0 (6.0 - 30.0) 7.0 (6.0 - 8.0) 12 (10.43)
29 (25.22)
39 (33.92) 35 (30.43)
Whitney U test and the Kruskal-Wallis
test were used for comparison when Table 1: Clinical migraine characteristics of the sample.
1 Migraine Disability Assessment Test score - Median (first-third quartile); 2
appropriate.
Two logistic regression models Number of days per trimester with pain - Median (first-third quartile); 3 0-10
Likert scale score - Median (first-third quartile); 4 Number (%) of subjects per
were performed in order to investigate diagnostic category
the influence of demographic and clinical variables (gender, diagnostic category, migraine disability, migraine frequency,
Migraine disability and psychological disorders
migraine intensity) on the presence of depressive
The mean MIDAS score was 12 ± 8.2. The
and/or anxiety symptoms, and on the coexistence
mean HAM-D score was of 8.65 ± 5.87. In particuof both disorders. We applied a backward eliminalar, we observed a minimal depression in 46 subtion stepwise procedure for the choice of the best
jects (40%), a mild depression in 64 subjects
predictive variables according to the Akaike infor(55.65%), a moderate depression in 3 subjects
mation criterion (AIC).
(2.61%), and a severe depression in 2 subjects
The effect of categorical independent variable
(1.74%). The mean HAM-A score was 10.56 ±
son the target variable were evaluated by means of
7.56, and we observed a minimal anxiety in 44
the Wald test. Statistical analysis was performed by
subjects (38.26%), a mild anxiety in 48 subjects
using the 2.15.3 version of the open-source soft(41.74%), a moderate anxiety in 20 subjects
ware R(18). A p-value < 0.05 was considered as sta(17.39%), and a severe anxiety in only 3 patients
tistically significant.
(2.61%).
An association between the occurrence of a
Results
psychological disorder and the level of disability is
emerged (X2 = 14.58, df = 3, p < 0.01). Indeed,
Clinical and demographical sample description
there existed a moderate correlation between
The study population consisted of 84 women
MIDAS scores and the occurrence of psychologiand 31 men with mean age of 44.2 ± 16.4 and 41.6
cal disorders (r = 0.32, p < 0.05), and a weak corre± 16.9 years, respectively. Neither demographic
lation between MIDAS and HAM-A scores (r =
(age, education) nor clinical significant differences
0.23, p < 0.05) as well as between MIDAS and
between men and women were found. We observed
HAM-D scores (r = 0.23, p < 0.05). A significant
a weak correlations between gender and pain intencorrelation between MIDAS score and pain intensity (r = 0.18), an association between gender and
sity was also found (r = 0.35, p < 0.001). A detailed
the occurrence of a psychological disorder (X2 =
description of the patient’s psychological condition
8.04, df = 1, p < 0.01) and between gender and the
by migraine disability level is reported in Table 2.
coexistence of anxiety and depressive disorders (X2
Comparing the psychological test scores by
= 5.61, df = 1, p < 0.05). Indeed, women had mean
disability subgroup, we found a significant differscores of HAM-D and HAM-A significant greater
ence between minimally and moderately disabled
than men (p < 0.01 in both cases), as well as the
patients (p < 0.01) and between mildly and modermean pain intensity (p < 0.05). Moreover, within the
ately disabled patients (p < 0.05). Finally, we
group of patients affected by anxiety disorder, the
found a significant difference in HAM-A and
women showed a mean MIDAS score significant
HAM-D scores between the patients who declared
greater than men (p < 0.05).
to suffer from headache until 10 days per trimester,
A clinical description of the sample is given in
and the patients who declared more than 10 days (p
Table 1.The mean headache frequency in the last
< 0.05 in both cases).
three months was 23.05 ± 25.52 days, with a peak
1
2
3
4
4
4
4
618
Francesco Corallo, Maria Cristina De Cola et Al
The physiological conditions of the patients
subdivided for diagnostic category are reported in
Table 3.
Minimal Disability1
Type of psychological
symptoms
migraine frequency (p = 0.2). In particular, mild
disability was the highest risk factor for a psychological disorder occurrence (Table 4).
Mild Disability1
Moderate Disability1
Severe Disability1
Total2
N
%
N
%
N
%
N
%
N
%
Only anxiety
2
6.06
1
5
6
21.43
4
11.76
13
11.3
Only depression
2
6.06
1
5
3
10.72
5
14.71
11
9.56
Anxiety and depression
comorbidity
14
42.42
9
45
17
60.71
18
52.94
58
50.44
None
15
45.45
9
45
2
7.14
7
20.59
33
28.7
Total2
33
28.7
20
17.39
28
24.35
34
29.56
115
100
Table 2: Anxiety and depressive characteristics for migraine disability level.
1 Percentage are computed using the number of patients in each migraine disability level; 2 Percentage are computed on the whole
sample dimension.
Migraine with aura
Migraine without aura
Chronic migraine
Patient’s condition
Tension-type
headache
N
%
N
%
N
%
N
%
Purely anxious (ANX)
1
8.33
4
13.79
5
12.82
3
8.57
Purely depressed (DEP)
0
-
6
20.69
4
10.26
1
2.86
Anxious and depressed
(COM)
6
50
11
37.93
22
56.41
19
54.28
Presence of a psychological disorder
(ANX+DEP+COM)
7
58.33
21
72.41
31
79.49
23
65.71
Absence of a psychological disorder
5
41.67
8
27.59
8
20.51
12
34.29
Table 3: Anxiety and depressive characteristics for type of migraine.
Percentage are computed using the number of patients in each diagnostic
category.
Risk factors for anxiety and depression
comorbidity in headache patients
Logistic regression analysis identified gender, age and headache frequency as feasible
risk factors; the headache intensity was not
significant (p = 0.96), as well as the diagnostic category (p = 0.3). Moderate
headache frequency was the highest risk
factor for a comorbidity of anxiety and
depressive disorders as compared to mild
and severe headache frequency (Table 5).
Independent variables
p-value
OR
0.007
0.27
Gender
Female
Risk factors for occurrence of anxiety or
depression symptoms in headache patients
The logistic regression analysis result identified as feasible risk factors only the variables gender and headache-related disability; the migraine
intensity was not significant (p = 0.57), as well as
the diagnostic category (p = 0.83), and the
Independent variables
p-value
OR
95% CI
Gender
Female
Male
0.27
0.10, 0.69
Migraine disability
Minimal
Male
1
0.09, 0.67
Migraine frequency*
Mild (≤ 10 days)
1
Moderate (11–29 days)
0.012
4.66
1.48, 16.97
Severe (≥ 30 days)
0.159
1.9
0.78, 4.75
Table 5: Backward logistic regression results: risk factors for anxiety and depressive comorbidity.
*Migraine frequency = number of days per trimester with pain
1
0.007
95% CI
1
Mild
0.002
3.74
1.64, 9.11
Moderate
0.251
0.55
0.18, 1.46
Severe
0.018
0.24
0.06, 0.71
Table 4: Backward logistic regression results: risk factors for anxiety and depressive occurrence.
Discussion
This study was designed to assess the relationship between disability (activity limitations) due to
headache or migraine and the presence of psychological disorders such as anxiety and depression. To
date, many studies reported an association between
migraine and some mental impairment(19,20), underlining that more than 25% of migraineurs meet criteria
for mood and anxiety disorders(21,22).
Assessment of anxiety, depressive disorders and pain intensity in migraine and tension headache patients
Differently from Mitsikostas et al.(11), where a
moderate intensity headache was associated only to
depression, we found that often depression and
anxiety occurred together. Indeed, our results
showed that 7/10 patients affected by headache or
migraine attacks also suffered from anxiety or
depressive disorders, and 1 out of 2 patients suffered from both disorders.
Anxiety and depression are often described as
a consequence of headache(23), but our findings suggestthat co morbidity with mental disorder is not
elective of specific diagnostic categories. Indeed,
the comparison analysis results conducted on the
HAM-D and HAM-A scores have confirmed that
the psychological condition of the patients is not
correlated with the diagnosis (migraine with aura,
migraine without aura, chronic migraine, and tension-type headache), but rather with the attack frequency.Chronic stress seems to affect the frequency of migraine attacks. Yavuz et al.(24) highlighted
that the stress due to a frequent headache attacks of
severe intensity, associated to depressive symptoms, affects the well-being of patients.
Chronic stress is one among the most significant risk factors for both depression and chronic
migraine(25,26). Previous studies have demonstrated
that, when compared to migraine, headache is
associated with greater disability and lower quality
of life(27-28). Other researches support the view that
psychiatric comorbidities can promote the transformation of episodic headaches into chronic daily
headache(29, 30). This transformation may increase
headache related disability, as well as the difficulty
to treat this disorder(17). Other studies have shown
that stress causes headaches and can be defined as
anxiety performance. Anxiety and depression seem
to aggravate the headache as well as negative emotions and mood disorders can create a fertile
ground for the development of the disease (31).
Similarly, our results have indicated a moderate
headache frequency as the highest risk factor for a
comorbidity of anxiety and depressive disorders.
Indeed, a high frequency attack, as well as their
intensity, restricts the social activities of the subject by risking to cause mood disorders. We also
found a significant correlation between intensity of
perceived pain and disability: the stronger was the
pain intensity, the greater the patient’s disability
was. Indeed, patients declared a reduction of the
social and professional activities because of the
pain.
619
According to previous studies(32, 33), our data
confirmed a difference between gender in terms of
psychological disorders, disability and pain intensity. In particular, women suffered from anxiety and
depression more than men, besides having a more
pronounced disability due to stronger pain attacks.
In fact, we found that female gender is one of the
major risk factor for the comorbidity of anxiety
and depressive disorders in migraineurs.
Considering the subsample composed by patients
with elevate MIDAS score, we observed that
women are considerably more anxious than men.
These are not unexpected findings because several
studies performed in clinical and community-based
settings have reported an association between
migraine and a number of specific psychiatric disorders in women(34).
It is important to consider the impact that the
disease has on the quality of life. Migraine and
headache cause significant limitations in all activities and in all roles of the individual, with obvious
consequences on the emotional and behavioural
and social aspects.
Given the complexity of the specific subject
we propose to extend the investigation trying to
increase the sample size and introducing the analysis of variables that would permit a better comprehensive assessment.
According to our findings, we believe that a
migraine condition may involve the onset of a
severe disability. Indeed, independently from the
diagnostic category, an high degree of disability is
often related to the presence of anxious and depressive symptoms. However, this study give only a
broad picture of the relationship between psychiatric symptoms and migraine disease, since the
rather small sample dimension. The knowledge of
the anxiety and depressive disorders could help to
improve the painful physical symptoms, the quality
of life and the prognosis of migraine and tension
type headache.
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_______
Correspoding author
FRANCESCO CORALLO, PSy
IRCCS Centro Neurolesi “Bonino-Pulejo”
S.S. 113, Via Palermo, C.da Casazza
98124 Messina
(Italy)