The Effect of Psychiatric Comorbidities on Headache-Related Disability in Migraine: Results From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study

Abstract

Objective: To examine the influences of depression and anxiety on headache-related disability in people with episodic migraine or chronic migraine.

Background: Depression and anxiety are common comorbidities in people with migraine, especially among those with chronic migraine.

Methods: This cross-sectional analysis of data from the longitudinal, internet-based Chronic Migraine Epidemiology and Outcomes Study assessed sociodemographic and headache features, and headache-related disability (Migraine Disability Assessment Scale). Four groups were defined based on scores from validated screeners for depression (9-item Patient Health Questionnaire) and anxiety (7-item Generalized Anxiety Disorder Scale): depression alone, anxiety alone, both, or neither.

Results: Respondents (N = 16,788) were predominantly women (74.4% [12,494/16,788]) and white (84.0% [14,044/16,788]); mean age was 41 years. Depression was more likely in persons with chronic migraine vs episodic migraine (56.6% [836/1476] vs 30.0% [4589/15,312]; P < .001), as were anxiety (48.4% [715/1476] vs 28.1% 4307/15,312]; P < .001) and coexisting depression and anxiety (42.0% [620/1476] vs 20.8% [3192/15,312]; P < .001). After controlling for headache frequency and other covariates, depression alone, and anxiety alone were associated with 56.0% (rate ratio [RR], 1.56; 95% confidence interval [CI], 1.46-1.66) and 39.0% (RR, 1.39; 95% CI, 1.30-1.50) increased risks of moderate/severe migraine-related disability (both P < .001), respectively; the combination had an even greater effect on risk of moderate/severe disability (79.0% increase; RR, 1.79; 95% CI, 1.71-1.87; P < .001).

Conclusions: Depression alone and anxiety alone are associated with greater headache-related disability after controlling for sociodemographic and headache features. Coexisting depression and anxiety are more strongly associated with disability than either comorbidity in isolation. Interventions targeting depression and anxiety as well as migraine itself may improve headache-related disability in people with migraine.

Keywords: anxiety; comorbidity; depression; headache‐related disability; migraine.

Fig 1

Respondent flow diagram. About 22,365 respondents abandoned the survey, were over quota, or had invalid (unusable) data and were removed during data cleaning. Met inclusion criteria: agreed to participate, screened positive for modified International Classification of Headache Disorders, third edition, migraine criteria, were ≥18 years of age, and had ≥1 headache in the previous 12 months. Note: There was 1 person with missing data for the anxiety and depression measures, so the sample size for this study differs by n = 1 from the total CaMEO baseline sample. Chronic Migraine Epidemiology and Outcomes (CaMEO); Chronic Migraine (CM); episodic migraine (EM).

Fig 2

Percentage of respondents with moderate or severe disability as indicated by a Migraine Disability Assessment Scale Grade of III or IV, stratified by presence of anxiety and/or depression. Migraine Disability Assessment Scale (MIDAS).

Fig 3

Predictors of headache‐related disability (MIDAS), as indicated by RRs and P values. The model was run adjusting for sex, age (in 10‐year increments), race (white vs nonwhite), BMI, annual household income, monthly headache‐day frequency, MSSS score (1‐point increments), and cutaneous allodynia. Sex, age in 10‐year increments, white race, BMI, monthly headache‐day frequency, MSSS score (1‐point increments), and cutaneous allodynia were all significant. Income brackets were also included in the model and were significant for $50,000 to $74,999 and ≥$75,000. The reference group had neither anxiety nor depression. Body mass index (BMI); Migraine Disability Assessment Scale (MIDAS); Migraine Symptom Severity Score (MSSS); rate ratio (RR).

Fig 4

Predicted MIDAS score by monthly headache days for each psychiatric subgroup. Note that for 0‐14 monthly headache days, the predicted mean MIDAS scores on the Y‐axis range from 0 to 60, whereas for 15‐30 monthly headache days, they range from 0 to 300. Migraine Disability Assessment Scale (MIDASs).