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ABSTRACT
ORIGINAL ARTICLE
The impact of anxiety and depression on migraine patients’
journey to a tertiary headache center
Impacto da ansiedade e depressão na jornada dos pacientes
com enxaqueca a um centro de cefaleia terciário
Érica C Santos
1,2
Juliane P P Mercante, PhD
3
André M S Silva, MD
4
Rosana T Miyazaki
5
Pamella F Daud
2
Arao B Oliveira, PhD
3
Mario F P Peres, PhD
1,3
1
Universidade de São Paulo, Faculdade de
Medicina, Instituto de Psiquiatria, São Paulo,
Brazil.
2
Universidade de São Paulo, Faculdade de
Neurociência e Comportamento, Instituto de
Psicologia, São Paulo, Brazil.
3
Hospital Israelita Albert Einstein, São Paulo,
Brazil.
4
Universidade de São Paulo, Faculdade de
Medicina, Departamento de Neurologia São
Paulo, Brazil.
5
Universidade de São Paulo, Faculdade de
Medicina, Instituto de Psiquiatria, São Paulo,
Brazil.
*Correspondence
Mario Fernando Prieto Peres
E-mail: marioperes@usp.br
Received: November 5, 2019.
Accepted: November 12, 2019.
Objective: To evaluate the role of psychiatric comorbidity in the number of
diagnostic procedures, acute and preventive pharmacological treatments,
and non-pharmacological interventions in migraine patients experienced
before visiting a tertiary headache center in São Paulo, Brazil. Methods: We
conducted a retrospective, observational study of 465 consecutive patients
diagnosed with migraines and evaluated in a specialized tertiary headache
center in São Paulo, Brazil. We collected the data based on medical chart
reviews and a self-administered questionnaire routinely performed during the
rst medical visit. Two standardized instruments were used for the diagnosis
of depression and anxiety, respectively: the Patient Health Questionnaire-9
(PHQ-9) and the Generalized Anxiety Disorder (GAD-7). Results: We studied
465 patients diagnosed with migraines. The patients’ mean age was 37.3 years
(±13.1), and 72.7% of patients were women. The average age of headache onset
was 17.1 years (±11.4) before the rst appointment at our tertiary headache
center, and 51.7% of patients had chronic migraines. Most patients (65.8%)
had a PHQ-9 ≥ 5, indicating at least some depressive symptoms, whereas 152
patients (34.2%) were considered depressed (PHQ-9 ≥ 9). Anxiety symptoms
were observed in 68.2% of patients based on the GAD-7 instrument, and 209
patients (47.0%) were diagnosed with anxiety (GAD-7 ≥ 8). Chronic migraines
were more common than episodic migraines among patients with psychiatric
comorbidity: 63.2% of depressive patients, 61.2% of anxious patients, and
43.5% of patients without any psychiatric disorder. Most patients underwent
laboratory tests and brain imaging (62.4% and 70.5%, respectively) in a similar
proportion among subgroups with and without anxiety or depression. Non-
pharmacological treatment was frequent in all subgroups, and 342 patients
(73.5%) performed at least one modality. Overall, acupuncture was the most
common non-pharmacological treatment (55.2% of patients), and we found
no difference between the subgroups. Depressive and anxious patients more
frequently underwent psychotherapy (54.2% and 50.8%, respectively) when
compared to patients with neither depression nor anxiety (34.7%). Depression
was associated with a reduced likelihood of previous physiotherapy (OR 0.39,
CI 0.16 – 0.99). Patients with severe anxiety used 10.7 times more medicines
than non-severe patients. Conclusion: Depressed patients underwent more
psychotherapy than non-depressed patients, although they had a reduced
chance of previous physiotherapy. Anxiety was also associated with previous
psychotherapy and a risk of 10.7 times of using acute pharmacological
treatment, which may lead to issues related to analgesic abuse. Anxiety and
depression affect the journey of patients with migraines before arriving at a
tertiary headache center.
Keywords: Migraine; Headache; Anxiety; Depression; Psychiatric Comorbidity.
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RESUMO
Objetivo: Avaliar o papel da comorbidade psiquiátrica no número de procedimentos
diagnósticos, tratamentos farmacológicos agudos e preventivos e intervenções não
farmacológicas em pacientes com enxaqueca experimentados antes de visitar um
Centro Terciário de Cefaleia em São Paulo, Brasil. Métodos: Realizamos um estudo
retrospectivo observacional de 465 pacientes consecutivos diagnosticados com
enxaqueca e avaliados em um centro especializado em cefaleia terciária em São Paulo,
Brasil. Coletamos os dados com base em revisões de prontuários médicos e em um
questionário autoaplicado rotineiramente realizado durante a primeira consulta médica.
Dois instrumentos padronizados foram utilizados para o diagnóstico de depressão
e ansiedade, respectivamente: o Questionário de Saúde do Paciente-9 (PHQ-9) e o
Transtorno de Ansiedade Generalizada (GAD-7). Resultados: Foram estudados 465
pacientes com diagnóstico de enxaqueca. A idade média dos pacientes foi de 37,3
anos (± 13,1) e 72,7% dos pacientes eram mulheres. A idade média do início da dor de
cabeça foi de 17,1 anos (± 11,4) antes da primeira consulta em nosso Centro Terciário
de Cefaleia, e 51,7% dos pacientes apresentavam enxaqueca crônica. A maioria dos
pacientes (65,8%) apresentou um PHQ-9 ≥ 5, indicando pelo menos alguns sintomas
depressivos, enquanto 152 pacientes (34,2%) foram considerados deprimidos (PHQ-9
≥ 9). Os sintomas de ansiedade foram observados em 68,2% dos pacientes com base
no instrumento GAD-7, e 209 pacientes (47,0%) foram diagnosticados com ansiedade
(GAD-7 ≥ 8). As enxaquecas crônicas foram mais comuns que as enxaquecas episódicas
em pacientes com comorbidade psiquiátrica: 63,2% dos pacientes depressivos, 61,2%
dos ansiosos e 43,5% dos pacientes sem nenhum transtorno psiquiátrico. A maioria
dos pacientes foi submetida a exames laboratoriais e imagens cerebrais (62,4% e
70,5%, respectivamente) em proporção semelhante entre os subgrupos com e sem
ansiedade ou depressão. O tratamento não farmacológico foi frequente em todos
os subgrupos e 342 pacientes (73,5%) realizaram pelo menos uma modalidade. No
geral, a acupuntura foi o tratamento não farmacológico mais comum (55,2% dos
pacientes), e não encontramos diferença entre os subgrupos. Pacientes depressivos
e ansiosos foram submetidos a psicoterapia com mais frequência (54,2% e 50,8%,
respectivamente) quando comparados aos pacientes sem depressão nem ansiedade
(34,7%). A depressão foi associada a uma probabilidade reduzida de sioterapia prévia
(OR 0,39, IC 0,16 - 0,99). Pacientes com ansiedade grave usavam 10,7 vezes mais
medicamentos do que pacientes não graves. Conclusão: Pacientes deprimidos foram
submetidos a mais psicoterapia do que pacientes não deprimidos, embora tivessem
uma chance reduzida de sioterapia anterior. A ansiedade também foi associada à
psicoterapia anterior e a um risco de 10,7 vezes do uso de tratamento farmacológico
agudo, o que pode levar a questões relacionadas ao abuso de analgésicos. Ansiedade
e depressão afetam a jornada de pacientes com enxaqueca antes de chegarem a um
Centro Terciário de Cefaleia.
Descritores: Enxaqueca, Dor de Cabeça, Ansiedade, Depressão, Comorbidade
Psiquiátrica.
INTRODUCTION
Migraine is a common chronic neurological disease
and a leading cause of disability worldwide, affecting
daily and social activities (1). In a study on the global
burden of disease, migraine had an average prevalence
of 14% and was the second highest contributor of
DALYs (disability-adjusted life-years) (2). In Brazil, the
population-based prevalence of migraine varies from
10.7% to 22.1% (3), and in tertiary care centers, migraines
represent 38% of all headaches (4).
Anxiety and mood disorders are the psychiatric
comorbidities most often associated with migraines. These
conditions are 2 to 10 times more common in patients
with migraines than in the general population, which
increases the complexity of their medical management
(5, 6). Patients with migraines and comorbid anxiety
and/or depression experience higher medical costs when
compared to patients with no comorbidities (7) due to
resource utilization, including medical visits, diagnostic
tests, and therapeutic interventions (8, 9). Additionally,
migraineurs are less optimistic and more pessimistic than
non-migraneurs, which may also inuence their medical
care seeking (10).
Patients with anxiety use health care services
for medical consultations, emergencies, and
examinations more often than individuals without
mental disorders (12.5 ± 8.1 vs. 2.4 ± 2.6 visits/year)
(11). In earlier surveys, anxiety and mood disorders
were consistently associated with substantial
impairments in both productive roles (e.g., work
absenteeism, work performance, unemployment, and
underemployment), social roles (e.g., social isolation,
interpersonal tensions, and marital disruption) (12, 13),
and greater stigma (14). Stigma is a signicant aspect
of mental and neurological conditions (15). It is a
process involving labeling, separation, knowledge and
emphasis of stereotypes, prejudice, and discrimination
in the context in which power is exercised over
disadvantaged members of a social group (16).
Tertiary headache centers usually manage more
difcult patients, including those with medical and
psychiatric comorbidities (5). Information regarding the
patient journey to a specialty headache care center is
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limited, and the inuence of psychiatric comorbidity on
the migraine patient journey is unknown.
In this study, we aimed to assess the role of psychiatric
comorbidity on the number of diagnostic procedures,
preventive and acute pharmacological treatments, and
non-pharmacological interventions migraine patients
experienced before visiting a tertiary headache center,
in São Paulo, Brazil. We hypothesized that anxiety and
depression increase the number of previous diagnostic
tests and treatment experiences.
METHODS
Study design
We conducted a retrospective, observational study of
465 consecutive patients with migraine diagnoses based
on the International Classication of Headache Disorders
– 3
rd
edition (ICHD-3). The patients were evaluated in
a specialized tertiary headache center from March to
July 2017, in São Paulo, Brazil. We collected the data
through medical chart reviews and a self-administered
questionnaire routinely used during initial medical visits.
The study was conducted in accordance with local laws
and was approved by the local ethics committee.
Eligibility criteria
Inclusion criteria were adult patients of both sexes over
18 years of age who were undergoing initial consultations
at a tertiary headache center in São Paulo. Exclusion
criteria included patients under 18 years, patients unable to
provide reliable information, and patients with signicant
cognitive decits or associated dementia.
Patient characteristics
We collected the following patient characteristics:
sociodemographic variables, headache characteristics,
previous diagnostic methods, clinical history, and
treatments previously used. Additionally, we used two
standardized instruments to diagnose depression and
anxiety, respectively: the Patient Health Questionnaire-9
(PHQ-9) and Generalized Anxiety Disorder (GAD-7).
Instruments and variable denitions
We dened patients with chronic migraines as
having headaches more than 15 days per month for at
least 3 months; patients with episodic migraines had
headaches fewer than 15 days per month.
To evaluate previous diagnostic methods
qualitatively, we asked patients if they had undergone
at least one of the following: laboratory test, cranial
computed tomography, cranial magnetic resonance,
electroencephalogram, and polysomnography.
Regarding previous treatments, we asked patients
if they had undergone at least one of the following:
acupuncture, psychotherapy, physiotherapy, botulinum
toxin, meditation, preventive medicines, and acute
medicines.
We dened depression based on the Patient Health
Questionnaire–9 (PHQ-9), which is designed for use with
adults to assess and monitor the severity of depression
according to the Diagnostic and Statistical Manual of
Mental Disorders (17) and International Classication of
Diseases, 10th Edition, diagnostic criteria (ICD-10) (18, 19).
The PHQ-9 includes nine items that evaluate symptoms
related to depressed mood, anhedonia (loss of interest or
pleasure in doing things), problems with sleep, tiredness
or lack of energy, change in appetite or weight, feelings
of guilt or uselessness, concentration problems, feeling
slow or restless, and suicidal thoughts. Final scores are
calculated by adding each response (“not all,” “several
days,” “more than half the days,” and “almost every day”)
and are classied into ve depression severity groups:
0-4: none; 5-9: mild; 10-14: moderate; 15-19: moderately
severe; 20-27: severe. However, based on a previous
Brazilian study that dened a score of 9 as the best point
of accuracy, and to assess depression as a dichotomized
variable, we divided the patients into two groups: with
depression if their PHQ-9 scores were greater than or
equal to 9, and without depression if their scores were
less than 9 (20).
Anxiety was dened based on the Generalized
Anxiety Disorder (GAD-7) scale, which consists of seven
items arranged on a 4-point Likert scale (0: not at all; 1:
several days; 2: more than half the days; 3: nearly every
day). Final scores are divided into four groups: 0-4:
minimal or no anxiety; 5-9: mild; 10-14: moderate; 15-21:
severe. (21). In our study, we consider a GAD-7 score
greater than or equal to 8 an anxiety diagnosis.
Statistical analysis
For subgroup comparison in a univariate analysis, we
used the qui-square test or Fisher’s exact test. To identify
variables independently related to depression and
anxiety symptoms, we categorized patients in four steps.
Initially, we dened two groups: patients with depression
and patients without depression. Next, we performed a
logistic regression to identify association of previously
performed exams and previously used treatments with
both groups. We then categorized patients as having
anxiety or not, and performed a new logistic regression
to study the same variable’s association with anxiety.
Finally, we performed a third logistic analysis to consider
the severe anxiety and severe depression subgroups.
We used IBM SPSS Statistics version 25 software (IBM,
Armonk, New York, USA) and considered a two-sided P
< 0.05 statistically signicant.
RESULTS
Sample characteristics
We studied 465 patients with migraine diagnosis;
their characteristics are summarized in Table 1. Their
mean age was 37.3 years (±13.1), and 72.7% of patients
were women. The patients’ average age at headache
onset was 17.1 years (±11.4) before the rst appointment
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at our tertiary headache center, and 51.7% of patients had
chronic migraines.
Most patients (65.8%) had a PHQ-9 ≥ 5, indicating at
least some depressive symptoms, whereas 152 patients
(34.2%) were considered depressed (PHQ-9 ≥ 9) (Table 1).
Symptoms of anxiety were observed in 68.2% of patients,
based on their GAD-7 scores, and 209 patients (47.0%)
were diagnosed with anxiety (GAD-7 ≥ 8). Depression and
anxiety were simultaneously diagnosed in 131 patients
(28.2%), and 237 patients (50.9%) had neither anxiety
nor depression. Other self-reported medical conditions
were common: 76.3% of patients had comorbidities,
such as gastritis, sinusitis, hypertension, kidney stones,
bromyalgia, and polycystic ovarian syndrome (Table 1).
We divided the patients into 4 subgroups:
depression, anxiety, depression and anxiety, and neither
depression nor anxiety. The characteristics evaluated
in comparison were migraine type, previous diagnoses
methods, and previous non-pharmacological and
pharmacological treatments.
Chronic migraines were more common than
episodic migraines among patients with psychiatric
comorbidities: 63.2% of depressive patients, 61.2% of
anxious patients, and 43.5% of patients without any
mood disorder experienced chronic migraines (Table 2).
Most patients underwent laboratory tests and
brain imaging (62.4 and 70.5%, respectively) in a similar
proportion among subgroups with or without anxiety or
depression (Table 2). One-third of patients underwent an
electroencephalogram before rst evaluation (Table 2).
Non-pharmacological treatment was frequent in all
subgroups, and 342 patients (73.5%) performed at least one
modality. Overall, acupuncture was the non-pharmacological
treatment most commonly done (55.2% of patients) without
difference between all subgroups. Depressive and anxious
patients (54.2% and 50.8%, respectively) more frequently
underwent psychotherapy compared to patients with
neither depression nor anxiety (34.7%) (Table 2). We found
no differences among the subgroups for other treatment
modalities, such as physiotherapy, botulinum toxin, nerve
blocks, and meditation.
Regarding pharmacological treatments, most patients
in all subgroups used preventive and acute treatments
(Table 2), although the proportion of acute medicine usage
was slightly higher than that of preventive medicine, even
in subgroups with mood disorders. Depressed patients
took preventive medications more often compared to non-
depressed patients (67.1% vs. 59.8%).
Multivariate analysis
Logistic regression was performed to identify factors
associated with depression and anxiety. Depressed
patients were more likely to be female (OR 8.18, CI 2.82 –
23.75), had more chronic migraines (OR 4.25, 1.90-9.50),
and had undergone more psychotherapy (OR 2.56, CI 1.15
– 5.66) than non-depressed patients (Table 3). In addition,
depression was associated with a reduced likelihood of
having previously undergone physiotherapy (OR 0.39,
CI 0.16 – 0.99). Anxiety was also associated with female
gender (OR 3.07, CI 1.36 – 6.95), chronic migraines (OR
3.91, CI 1.90 – 8.04), and previous psychotherapy (OR 2.18,
Sociodemographic and clinical
characteristics
N or
years
% or
SD
Age (Mean ± SD, n=462) 37.3 13.1
Duration of migraine in years (Mean ± SD,
n=462)
17.2 11.4
Gender (n=462)
Men 126 27.3
Women 336 72.7
Religion (n=239)
Yes 204 85.4
Without religion 35 14.6
Migraine type
Chronic 240 51.7
Episodic 224 48.3
Patient Health Questionnaire - 9 (PHQ-9)
(n=445)
Minimal or none (score 0-4) 152 34.2
Mild (score 5-9) 152 34.2
Moderate (score 10-15) 75 16.9
Moderately severe (score 15-19) 35 7.9
Severe (score 20-27) 31 7.0
General Anxiety Disorder - 7 (GAD-7)
(n=445)
None (score 0-4) 139 31.2
Mild (score 5-9) 144 32.4
Moderate (score 10) 93 20.9
Severe (score 15-21) 69 15.5
Final mood diagnosis (n=445)
Depression (PHQ-9≥9) 152 34,2
Anxiety (GAD-7≥8) 209 47.0
Depression and anxiety (PHQ-9≥9 and
GAD-7≥8)
131 28.2
No depression or anxiety (PHQ-9<9 and
GAD-7<8)
237 50.9
Medical comorbidities (n=465)
Rhinitis 180 50.7
Sinusitis 175 49.3
Gastritis 173 48.7
Kidney stone 66 18.6
Polycystic ovary 58 16.3
Hypertension 39 11.0
Endometriosis 22 6.2
Fibromyalgia 21 5.9
Any medical comorbities (n=465) 355 76.3
Tabacco use (n=435) 30 6.5
Alcohol use (n=465) 214 46.0
Table 1. Patients characteristics with migraine.
SD: Standard deviation.
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Table 2. Comparison based in the presence of anxiety and depression
Patients (n=465)
Depression (D) Anxiety (A) D + A Without D or A All patients
N= 152 N=209 N=131 N=237 N=465
N % N % N % N % N %
Migraine Type*
Chronic 96/152 63.2 128/209 61.2 84/131 64.1 103/237 43.5 240 51.7
Episodic 56/152 36.8 81/209 38.8 47/131 35.9 134/237 56.5 224 48.3
Previous test
Laboratory tests 100/152 65.7 134/209 64.1 86/131 65.6 156/237 65.8 290 62.4
Cranial CT 92/152 60.5 130/209 62.2 85/131 64.9 130/237 54.9 260 55.9
Cranial MRI 94/152 61.8 126/209 60.3 84/131 64.1 133/237 56.1 259 55.7
Cranial CT or MRI 112/152 73.7 154/209 73.7 98/131 74.8 168/237 70.9 328 70.5
EEG 57/ 1 52 37.5 80/209 38.3 49/131 37.4 83/237 35.0 163 35.1
Non-pharmacological treatments
Any non-
pharmacological
119/152 78.3 164/209 78.5 105/131 80.2 178/237 75.1 342 73.5
Acupuncture 81/141 57.4 117/196 59.7 73/122 59.8 116/226 51.3 233 55.2
Psychotherapy* 77/142 54.2 100/197 50.8 70/123 56.9 78/225 34.7 178 42.2
Physiotherapy 39/141 27.7 60/196 30.6 32/122 26.2 69/223 30.9 129 30.8
Botulinum Toxin 22/141 15.6 31/196 15.8 21/122 17.2 36/225 16.0 67 15.9
Nerve Blockade 35/141 24.8 44/196 22.4 28/122 23.0 47/ 2 24 21.0 91 21.7
Meditation 19/141 13.5 34/196 17.3 16/122 13.1 41/225 18.2 75 17.8
Pharmacological treatments
Preventive
medicines
102/152 67.1 132/209 63.2 84/122 64.1 144/235 61.3 276 59.6
Acute medicines 103/152 67.8 139/209 66.5 88/131 67.2 150/235 63.8 289 62.4
* numbers in bold present results with difference statistically signicant (p<0.05). D: Depression; A: Anxiety.
Table 3. Multivariate analysis for presence of depression
Variables B Wald OR 95% Condence interval p-value
Age (years) -0.05 5.34 0.95 0.92 – 0.99 0.021
Female 2.10 14.95 8.18 2.82 – 23.75 0.000
Having religion 0.60 1.41 1.82 0.68 – 4.88 0.235
Disease duration (years) 0.03 2.05 1.03 0.99 – 1.08 0.152
Chronic migraine 1.45 12.48 4.25 1.90 – 9.50 0.000
Alcohol use 0.49 1.62 1.63 0.77 – 3.46 0.202
Tobacco use 0.40 0.35 1.48 0.40 – 5.47 0.552
Presence of any comorbidity 0.35 0.46 1.42 0.51 – 3.92 0.499
Cranial MRI 0.44 1.04 1.55 0.67 – 3.60 0.308
Cranial CT -0.13 0.09 0.88 0.39 – 1.99 0.759
Laboratory tests -0.06 0.02 0.94 0.42 – 2.10 0.877
EEG ,0.14 0.11 1.16 0.50 – 2.69 0.737
Acupuncture 0.06 0.03 1.07 0.49 – 2.31 0.869
Psychotherapy 0.94 5.34 2.56 1.15 – 5.66 0.021
Physiotherapy -0.92 3.97 0.40 0.16 – 0.99 0.046
Botulinum toxin 0.29 0.30 1.34 0.47 – 3.78 0.582
Nerve Blockade -0.39 0.66 0.67 0.26 – 1.74 0.417
Meditation -0.82 2.77 0.44 0.17 – 1.16 0.096
Preventive medicines -0.71 2.16 0.49 0.19 – 1.27 0.141
Acute medicines 0.41 0.83 1.51 0.62 – 3.67 0.362
* numbers in bold present results with difference statistically signicant (p<0.05)
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CI 1.07 – 4.47). In addition, anxious patients were less likely
to undergo laboratory tests (OR 0.40, CI 0.19 – 0.85).
Furthermore, we performed a logistic regression
to determine whether severe depression (65 patients)
and severe anxiety (69 patients) were associated with
the same variables. We found that severe depression
was also associated with chronic migraines (OR 4.72, CI
1.53 – 14.56) and female gender (OR 4.62, CI 13-18) and
tended to be associated with previous psychotherapy
(OR 2.72, CI 0.96-7.69). The inverse relationship between
depression and previous physiotherapy was not found
in the severe group. Severe anxiety was also associated
with fewer laboratory tests (OR 0.23, CI 0.09 – 0.60) and
chronic migraines (OR 3.15, CI 1.20 – 8.23). In addition, we
found that severe anxiety patients used 10.7 times more
acute medication than non-severe anxiety patients (OR
10.71, CI 2.60 – 44.08).
DISCUSSION
In our study of migraine patients at a tertiary
headache center, we found depressive symptoms in
65.8% of patients and a depression prevalence of 34.2%.
The prevalence of anxiety was 47.0%, whereas 68.2%
of patients had some anxiety symptoms. Anxiety and
depression were present simultaneously in 28.2% of
patients, (Table 1) and these conditions were strongly
associated with chronic migraines and female gender.
These results align with recent studies that reported
high prevalence of the same psychiatric comorbidities
in patients with chronic migraines (1, 5, 6, 22, 23). The
analysis of previous patient journeys showed that
depressive patients underwent more psychotherapy
and less physiotherapy than non-depressed patients,
whereas anxiety was associated with a higher probability
of undergoing psychotherapy, but a lower probability of
undergoing laboratory tests. Additionally, severe anxiety
increased the risk of using acute medication by 10.7 times.
Patients with migraines frequently have multiple medical
visits before arriving at a tertiary center. Reported on
primary care provided by non-specialists and found
that headache patients had an average of 3 health care
providers prior to consultation with a specialist, with an
average of 11 years of pain duration (24). In our tertiary
headache center, the mean headache duration was 17.1
years (±11.4) before the rst appointment, and most
patients had already performed non-pharmacological
treatments and used preventive medicine. Therefore,
considering the high prevalence of mood symptoms
in migraineurs, non-specialists should be trained in the
management of psychiatric comorbidities in headache
disorders to improve the patient journey.
Regarding ancillary tests performed during
headache diagnosis, cranial computed tomography and
magnetic resonance imaging permit the exclusion of
certain secondary causes of headaches, such as brain
masses and vascular diseases, but their usefulness is
signicantly reduced in patients with chronic headaches.
We consider the previous cranial imaging undergone
by 70% of our patients to be quite unwarranted, as is
the high frequency of previous Electroencephalogram
(EEG) (one-third of our patients had undergone at least
one), which is usually unnecessary for migraine patients.
A detailed evaluation of other symptoms indicative of
secondary headaches should always be considered, so
excessive and costly tests may be precluded in patients
with evident migraine criteria unless other warning signs
are present (25).
We expected more migraine patients with
psychiatric comorbidities to have undergone diagnostic
tests than those without comorbidities, as observed in
previous reports (5, 26), but our study did not conrm
these ndings. This could be due to a trend among
primary physicians of asking tests for most headache
patients, regardless of psychiatric comorbidities.
Another explanation is the fact that we did not quantify
the number of tests performed, but asked the patients if
they underwent a specic test at least once in the past.
In addition, stigma may be an issue, as patients with
anxiety or depression may not be evaluated adequately
and may give up seeking a correct diagnosis. A nding
that supports this hypothesis is that anxious patients
in our study were less likely to undergo laboratory
tests, although one would predict the opposite due to
increased somatization and physical symptoms.
Non-pharmacological treatment was frequent;
patients in all subgroups performed at least one
modality. Interestingly, previous experience with
psychotherapy was frequently a predictor of anxiety and
depression in migraine patients. This could be explained
by previous referrals from physicians or self-referrals
to psychotherapy. More severe patients should have
greater need for medication and non-pharmacological
approaches, but in this case, we found only psychotherapy
and, interestingly, reduced odds of undergoing physical
therapy. The low probability of undergoing physical
therapy could be due to kinesiophobia, a phenomenon
related to the avoidance of physical therapy in the
treatment of chronic pain, in patients with depression
and anxiety (26, 27). Besides the overuse of health care
services, anxiety and depression are both associated
with signicant psychological distress and poor health
perception, whereas physical disability is only associated
with depression and may corroborate the kinesiophobia
(28).
We found no independent association
between depression and a higher likelihood of using
pharmacological treatment. One explanation for this
lack of correlation may be the way we veried the use of
medication. In our study, we did not quantify the number
or duration of drugs previously tried, but evaluated
these factors qualitatively (used or not used). However,
we found a strong association between severe anxiety
and acute medicine consumption. Higher anxiety levels
could cause patients to seek more care and receive
more preventive treatments, but patients may also
use analgesics excessively due to cephalalgiaphobia,
anticipatory anxiety, or compulsion (29). Severe anxiety
patients used 10.7 times more acute medicines than
non-severe anxiety patients. This is also in accordance
with other studies’ ndings. Showed that analgesic
consumption was greater in GAD patients with primary
The impact of anxiety and depression on migraine patients
Santos ÉC, et al.
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headaches than in controls with primary headaches
without GAD (11). Analgesics ingestion can occur prior
to the onset of a headache due to anxiety, and evaluated
the reasons for this behavior: 67% of patients reported
difculty coping with pain, 62% feared its emergence,
and 45% consumed analgesics to reduce anxiety (30).
Our study has some limitations. First, it was an
observational cross-sectional study based on medical
charts and a retrospective self-reported questionnaire,
so associations found may be not due to a cause–effect
relationship. Second, patients were asked to remember all
previously performed procedures, which can be inuenced
by reminder bias. Finally, we performed a single-center
study. Thus, our study reected a specic population, and
selection bias may be have inuenced our results.
CONCLUSION
Anxiety and depression were common in migraine
patients seen at a tertiary headache center, mostly in
patients with chronic migraines. Depressed patients
were often female, had more chronic migraines,
and had undergone more psychotherapy than non-
depressed patients, although they had a reduced
chance of having previously undergone physiotherapy.
Anxiety was also associated with female gender,
chronic migraines, previous psychotherapy, and a risk
of using acute pharmacological treatment that was 10.7
times higher than in other patient groups, which may
lead to issues related to analgesic abuse. Anxiety and
depression affect the journey of patients with migraines,
probably beginning with primary care, and physicians,
who routinely offer rst-aid interventions, should be
concerned with recognizing these mental disorders.
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