Associations Between Depression/Anxiety and Headache Frequency in Migraineurs

A Cross-Sectional Study

Hsuan-Te Chu, MD; Chih-Sung Liang, MD; Jiunn-Tay Lee, MD; Ta-Chuan Yeh, MD; Meei-Shyuan Lee, PhD; Yueh-Feng Sung, MD, PhD; Fu-Chi Yang, MD, PhD


Headache. 2018;58(3):407-415. 

In This Article

Abstract and Introduction


Background While migraines have been associated with emotional disturbances, it remains unknown whether the intensity of emotional expression is directly related to migraine frequency.

Objective The present study investigated depression/anxiety among migraineurs.

Methods This cross-sectional study included 588 clinical outpatients in Taiwan. Migraines were stratified by attack frequency, with and without auras, and with well-controlled confounding variables. Demographic and clinical data, including sleep characteristics, were collected. Multivariable linear regressions were employed to examine whether migraine frequency (1-4 headache days per month, 5–8 headache days per month, 9–14 headache days per month, or >14 headache days per month) was associated with depression/anxiety symptoms, as indicated by the Beck's Depression Inventory (BDI) and Hospital Anxiety and Depression Subscales (HADS).

Results BDI total scores were highest in patients with chronic migraines (mean ± SD: 13.2 ± 8.5), followed by those with high frequency (12.1 ± 8.5), medium frequency (10.6 ± 8.0), low frequency (9.1 ± 7.1), and lowest in nonmigraine controls (6.6 ± 5.9), with a significant trend in frequency (P trend < .001); similar results were obtained for HADS scores. BDI and HADS scores were independently related to high-frequency episodic and chronic migraine frequency and to poor sleep quality. The relationship between BDI score and migraine frequency was present in both aura-present (P trend = .001) and aura-absent subgroups (P trend = .029).

Conclusion Higher migraine frequency, either with or without auras, correlated with higher symptom scores of anxiety and depression.


Headache, a common somatic problem, can result in emotional distress and disruption of daily life. The World Health Organization has recognized primary headache disorders, including migraines, as important public health issues owing to their high prevalence, wide demographic distribution, and important functional and socioeconomic implications.[1] The most common comorbidities in patients with migraines are anxiety and depression,[2] followed by sleep disturbances.[3,4] These disorders are reported to be contributory factors in triggering migraines, but may also be due to recurrent, severe migraine attacks.[5]

The association of depression and anxiety with headache depends more on headache frequency than diagnostic category (eg, migraine or tension-type headaches).[6] Furthermore, headache frequency is an important predictor of health-related quality of life.[7] Affective comorbidities increase migraine-associated health care costs and utilization,[8] worsen quality of life, and can lead to disability.[9] Migraineurs tend to experience heightened anxiety and emotional stress as well as disturbed contentment, vitality, and sleep, even during headache-free periods during which there is fear of impending attacks.[10] Interestingly, women who suffer from migraines with auras suffer from depression and anxiety more frequently than those without auras.[11]

There may be a bidirectional association between depression, migraines,[12] and headache characteristics, including frequency, as these factors tend to have a strong influence on anxiety and depression symptoms, as well as on quality of life.[13] Migraineurs are also more likely to suffer from comorbid depression and anxiety than either comorbidity alone.[14] Moreover, increased migraine frequency is associated with an increased risk of mood/anxiety disorders.[15] However, the linear correlation between migraine frequency and mood/anxiety disorders is still not clear. It is not distinguished by grouping frequency of migraine attacks, whether it is associated with severity scores of depression and anxiety, and with or without aura compared to controlled subjects.

In the present study, we tested the hypothesis that migraine frequency may be predictive of depression/anxiety severity, regardless of the presence of auras. Specifically, we evaluated the relationship between severity of depression/anxiety and migraine frequency while controlling for potentially confounding factors (eg, sleep quality, employment, education, smoking status, and alcohol and coffee consumption).