Migraine is a recurrent neurological disorder characterised by episodic headache, sensory hypersensitivity, autonomic symptoms, and variable functional impairment. It represents an important cause of disability because it commonly affects individuals during economically and socially productive years. The burden of migraine extends beyond headache intensity and includes restrictions in employment, education, household activities, interpersonal relationships, and quality of life.

Comorbidity refers to the coexistence of an additional disorder in an individual with an index disease.[1] Psychiatric comorbidity, particularly anxiety and depression, is frequently reported among individuals with migraine.[2,3] The relationship between migraine and mood disorders is clinically important because each condition may influence the presentation, severity, treatment response, and long-term course of the other.

Depressive and anxiety symptoms may contribute to increased headache frequency, impaired coping, poor adherence to treatment, medication overuse, sleep disturbance, and progression from episodic to chronic migraine.[4,5] Conversely, recurrent painful attacks, anticipatory fear of future episodes, and disruption of social and occupational activities may contribute to psychological distress.

The detection of mood symptoms among patients with migraine may be difficult in routine neurological practice because consultations frequently focus on headache characteristics and pharmacological treatment. Standardised screening instruments may help identify individuals requiring more detailed psychological or psychiatric evaluation. The Hospital Anxiety and Depression Scale is a brief instrument designed to assess anxiety and depressive symptoms while minimising the influence of physical symptoms.[7]

Migraine-related disability can be assessed using the Migraine Disability Assessment questionnaire, which measures the effect of headache on work, household activities, and social functioning during the preceding three months.[6] Evaluating both psychological symptoms and functional disability may provide a more complete assessment of disease burden than documenting headache frequency and severity alone.

Previous studies have reported considerable variation in the prevalence of anxiety and depression among migraineurs.[8–11] Differences in study populations, diagnostic criteria, clinical settings, exclusion criteria, and assessment instruments may partly explain this variation. Hospital-based studies are particularly useful for characterising patients who seek specialist care, although they may include individuals with more severe or disabling disease.

The present study was undertaken to determine the prevalence of anxiety and depressive symptoms among patients with migraine and to describe the clinical characteristics and migraine-related disability of the study population.

Study design and setting This hospital-based cross-sectional observational study was conducted in the Outpatient Department of General Medicine from November 2023 to October 2024. Study population and sampling Patients presenting with recurrent headache were clinically evaluated for eligibility. Those fulfilling the International Classification of Headache Disorders, third edition criteria for migraine were included. A total of 150 eligible participants were enrolled by consecutive sampling. Eligibility criteria Patients aged ≥18 years who fulfilled the diagnostic criteria for migraine, had experienced migraine for at least six months, were able to complete the study questionnaires, and provided written informed consent were included. Patients with secondary headache, another primary headache disorder, medication-overuse headache, headache of less than six months’ duration, recent hormonal contraceptive use, severe concurrent medical illness, a previously diagnosed psychiatric disorder, or use of migraine-prophylactic medication during the preceding six months were excluded. Clinical assessment Participants underwent detailed clinical evaluation using a structured questionnaire. Information was collected regarding migraine duration, frequency and duration of attacks, pain location and character, headache severity, aura, nausea or vomiting, photophobia and phonophobia, menstrual association, precipitating factors, headache-associated mood changes, and effects on personal, occupational, and social functioning. Assessment of migraine-related disability Migraine-related disability was assessed using the Migraine Disability Assessment questionnaire.[6] The MIDAS questionnaire records the number of days during the preceding three months on which migraine interfered with paid work, education, household activities, and social or leisure activities. MIDAS scores were classified as follows: MIDAS score Disability category 0–5 Little or no disability 6–10 Mild disability 11–20 Moderate disability ≥21 Severe disability Any migraine-related disability included mild, moderate, and severe disability. Moderate-to-severe disability included participants classified as having moderate or severe disability. Clinical investigations Magnetic resonance imaging of the brain was performed to exclude structural intracranial lesions. Laboratory investigations included complete blood count, erythrocyte sedimentation rate, routine blood biochemistry, and additional investigations when clinically indicated. Outcome measures The primary outcomes were the prevalence of depressive symptoms according to the HADS-Depression subscale, the prevalence of anxiety symptoms according to the HADS-Anxiety subscale, and the distribution of migraine-related disability according to the MIDAS classification. Secondary outcomes included the distribution of sociodemographic characteristics, migraine-associated clinical features, and factors associated with headache-related mood changes. Statistical analysis Categorical variables were summarized as frequencies and percentages. Age was expressed as mean and standard deviation. Total migraine duration, attack frequency, and duration of individual attacks were summarized using medians because these variables were non-normally distributed. Percentages were calculated using the total sample of 150 unless otherwise specified. Anxiety and depressive symptoms were analyzed separately because they were not mutually exclusive. Associations between categorical variables and headache-related mood changes were assessed using the Pearson chi-square test or Fisher’s exact test, as appropriate. Non-normally distributed continuous or ordinal variables were compared using the Mann–Whitney U test. All statistical tests were two-sided, and a P value <0.05 was considered statistically significant.

Sociodemographic characteristics

A total of 150 participants were included in the study. The mean age was 34.13 ± 8.49 years. Most participants were between 25 and 50 years of age, accounting for 123 (82.0%) of the study population. The remaining 27 participants (18.0%) belonged to other age groups.

Females constituted the majority of the study population, with 117 participants (78.0%), whereas 33 participants (22.0%) were male (Table 1).

Table 1. Sociodemographic characteristics of the participants (N = 150)

Mean age: 34.13 ± 8.49 years.

Distribution of anxiety and depressive symptoms

Depressive symptoms were identified in 14 participants, corresponding to a prevalence of 9.3%. The remaining 136 participants (90.7%) did not have depressive symptoms.

Among the 14 participants with depressive symptoms, 6 (42.9%) had borderline abnormal HADS-Depression scores and 8 (57.1%) had abnormal scores. The mean HADS-Depression score among participants with depressive symptoms was 11.25 ± 3.05.

Anxiety symptoms were identified in 25 participants, giving a prevalence of 16.7%, while 125 participants (83.3%) did not have anxiety symptoms. Among participants with anxiety symptoms, 5 (20.0%) had borderline abnormal scores and 20 (80.0%) had abnormal scores. The mean HADS-Anxiety score among participants with anxiety symptoms was 13.82 ± 2.72.

Anxiety symptoms were therefore more frequent than depressive symptoms in the study population (Table 2).

Table 2. Distribution of anxiety and depressive symptoms according to HADS (N = 150)

1. Overall distribution

1. Distribution among participants with depressive symptoms

1. Distribution among participants with anxiety symptoms

Mean HADS-Depression score: 11.25 ± 3.05.
Mean HADS-Anxiety score: 13.82 ± 2.72.

Clinical characteristics of migraine

Photophobia and phonophobia were the most frequently reported migraine-associated manifestations and were present in 115 participants (76.7%). Nausea and/or vomiting were reported by 92 participants (61.3%).

Mood changes associated with migraine were reported by 38 participants (25.3%). Aura was present in 24 participants (16.0%), while 126 (84.0%) did not experience aura.

Menstrual headache was reported by 23 participants (15.3% of the total study population), while menstrual mood changes were reported by 5 participants (3.3%).

The median total duration of migraine was 6 years, and the median duration of individual migraine attacks was 8 hours (Table 3).

Table 3. Clinical characteristics of migraine among the participants (N = 150)

Median total duration of migraine: 6 years.
Median duration of each migraine attack: 8 hours.

Migraine-related disability

According to the MIDAS classification, 49 participants (32.7%) had no migraine-related disability. Mild disability was identified in 1 participant (0.7%). Moderate disability was the most common category and was observed in 61 participants (40.7%), while 39 participants (26.0%) had severe disability.

Overall, 101 participants (67.3%) experienced some degree of migraine-related disability. Moderate-to-severe disability was present in 100 participants (66.7%) (Table 4).

Table 4. Migraine-related disability according to the MIDAS classification (N = 150)

*Any migraine-related disability includes mild, moderate, and severe disability.

Moderate disability was the most common MIDAS category. More than two-thirds of the participants had some degree of migraine-related disability, and nearly all participants with disability were classified as having moderate or severe functional impairment.

FIGURE 1 — Sociodemographic characteristics

FIGURE 2 — HADS depression and anxiety distribution

FIGURE 3 — Clinical characteristics of migraine

FIGURE 4 — MIDAS migraine-related disability

FIGURE 5 — Factors associated with migraine-related mood changes

The present study describes anxiety and depressive symptoms, migraine-associated clinical features, and functional disability among 150 patients with migraine. The study population was predominantly female, with a mean age of approximately 34 years. Anxiety symptoms were identified in 16.7% of participants, while depressive symptoms were present in 9.3%. Approximately one-quarter reported mood changes associated with migraine attacks. Migraine-related disability was common, with 67.3% experiencing at least mild disability and 66.7% experiencing moderate-to-severe disability. The female predominance observed in the present study is consistent with the recognised epidemiological pattern of migraine. Hormonal influences, differences in pain processing, genetic susceptibility, psychosocial factors, and healthcare-seeking behaviour may contribute to the higher representation of women in both population-based and hospital-based migraine cohorts. The prevalence of anxiety symptoms was higher than that of depressive symptoms. Previous studies have also reported that anxiety disorders may occur more frequently than depressive disorders among migraineurs.[12,13] Anxiety may be related to anticipatory concerns about future attacks, uncertainty regarding attack onset, fear of disability, avoidance of potential triggers, and disruption of professional and social activities. The observed prevalence of depressive symptoms falls within the broad range reported in migraine populations.[2,8,9] Published estimates vary substantially because of differences in diagnostic definitions, population characteristics, study settings, headache classification, and the screening or diagnostic instruments used.[22–25] Hospital-based studies may include individuals with more frequent or disabling migraine, while screening instruments may identify symptom burden without establishing a formal psychiatric diagnosis. The HADS was selected because it is brief, convenient for outpatient use, and focuses largely on psychological manifestations rather than somatic complaints.[7] This characteristic is useful in migraine studies because fatigue, sleep disturbance, impaired concentration, and bodily discomfort may arise from either headache or mood disorders. However, HADS remains a screening instrument and cannot replace a structured psychiatric diagnostic interview. Photophobia and phonophobia were the most common migraine-associated manifestations, occurring in more than three-quarters of participants. Nausea and/or vomiting were reported by approximately three-fifths of the sample. These findings reflect the sensory and autonomic manifestations typically accompanying migraine attacks. Aura was reported by 16.0% of participants. Although aura represents an important clinical subtype of migraine, its relationship with psychological symptoms remains inconsistent across studies. Some investigations have reported associations between migraine features and anxiety or depressive symptoms, whereas others have found that attack burden and disability are more important than the presence of aura itself.[10,12] Mood changes temporally associated with migraine were reported by approximately one-quarter of the participants. Such changes may reflect psychological reactions to recurrent pain, premonitory or postdromal manifestations, impaired functioning during attacks, or shared biological pathways. Migraine and mood disorders may involve overlapping neural circuits encompassing the amygdala, anterior cingulate cortex, periaqueductal grey, brainstem monoaminergic nuclei, and other structures involved in nociception and emotional processing.[17,18] The most clinically important finding was the high burden of migraine-related disability. Moderate disability was the most common MIDAS category, while more than one-quarter of the participants had severe disability. Overall, 67.3% experienced some degree of disability and 66.7% had moderate-to-severe disability. These findings indicate that headache diagnosis alone may not adequately represent the burden experienced by patients. Two individuals with similar headache frequency may differ substantially in their ability to work, perform household activities, participate in social events, and maintain family responsibilities. Disability assessment may therefore help clinicians identify patients requiring preventive treatment, closer follow-up, workplace interventions, lifestyle modification, or multidisciplinary care. Previous research has shown that psychiatric comorbidity may increase migraine-related disability, healthcare utilisation, absenteeism, and impairment in quality of life.[13,19,20] An Indian headache-clinic study also reported substantial impairment in health-related quality of life among migraine patients and demonstrated that depressive and anxiety symptoms were associated with poorer functional outcomes.[21] The relationship between migraine and mood disorders may be bidirectional. Recurrent migraine attacks may contribute to anxiety and depression through chronic pain, functional limitation, and uncertainty. Conversely, psychological distress may influence pain perception, sleep, coping behaviour, treatment adherence, and the progression from episodic to chronic migraine.[14–16] These observations support the integration of mental-health screening into routine migraine care. Brief instruments such as HADS may identify patients requiring further evaluation, while MIDAS can quantify functional impairment and assist in treatment planning. Patients with abnormal screening results should undergo appropriate clinical assessment rather than being diagnosed solely on the basis of questionnaire scores. Strengths The study used standardised diagnostic and assessment instruments for migraine, mood symptoms, and disability. Patients with other primary headaches, secondary headaches, known psychiatric disease, and recent prophylactic medication use were excluded to reduce important sources of clinical confounding. The assessment included detailed headache characteristics, migraine-associated manifestations, neuroimaging, and relevant laboratory investigations. Limitations The cross-sectional design prevents determination of the temporal or causal relationship between migraine and psychological symptoms. No non-migraine control group was included. The numbers of participants with anxiety and depressive symptoms were relatively small. The study did not evaluate the overlap between anxiety and depressive symptoms, migraine subtype, medication use, sleep disturbance, socioeconomic factors, or other potential confounders.

Anxiety symptoms were more common than depressive symptoms among patients with migraine. Photophobia, phonophobia, nausea, and vomiting were common migraine-associated manifestations.

Migraine-related disability affected more than two-thirds of the participants. Moderate disability was the most frequent MIDAS category, and approximately two-thirds had moderate-to-severe functional impairment.

Routine assessment of anxiety, depressive symptoms, and functional disability should be considered as part of comprehensive migraine care. Patients with clinically relevant screening results should receive appropriate psychological or psychiatric evaluation and integrated management.

1. Feinstein AR. The pre-therapeutic classification of co-morbidity in chronic disease. J Chronic Dis. 1970;23:455–468.
2. Antonaci F, Nappi G, Galli F, Manzoni GC, Calabresi P, Costa A, et al. Migraine and psychiatric comorbidity: A review of clinical findings. J Headache Pain. 2011;12:115–125.
3. Breslau N. Psychiatric comorbidity in migraine. Cephalalgia. 1998;18 Suppl 22:56–58.
4. May A, Schulte LH. Chronic migraine: Risk factors, mechanisms and treatment. Nat Rev Neurol. 2016;12:455–464.
5. Smitherman TA, Maizels M, Penzien DB. Headache chronification: Screening and behavioral management of comorbid depressive and anxiety disorders. Headache. 2008;48:45–50.
6. Stewart WF, Lipton RB, Dowson AJ, Sawyer J. Development and testing of the Migraine Disability Assessment questionnaire to assess headache-related disability. Neurology. 2001;56 Suppl 1:S20–S28.
7. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67:361–370.
8. Lipton RB, Hamelsky SW, Kolodner KB, Steiner TJ, Stewart WF. Migraine, quality of life, and depression: A population-based case-control study. Neurology. 2000;55:629–635.
9. Zwart JA, Dyb G, Hagen K, Ødegård KJ, Dahl AA, Bovim G, et al. Depression and anxiety disorders associated with headache frequency: The Nord-Trøndelag Health Study. Eur J Neurol. 2003;10:147–152.
10. Oedegaard KJ, Neckelmann D, Mykletun A, Dahl AA, Zwart JA, Hagen K, et al. Migraine with and without aura: Association with depression and anxiety disorder in a population-based study. Cephalalgia. 2006;26:1–6.
11. Lampl C, Thomas H, Tassorelli C, Katsarava Z, Laínez JM, Lantéri-Minet M, et al. Headache, depression and anxiety: Associations in the Eurolight project. J Headache Pain. 2016;17:59.
12. Baldacci F, Lucchesi C, Cafalli M, Poletti M, Ulivi M, Vedovello M, et al. Migraine features in migraineurs with and without anxiety-depression symptoms: A hospital-based study. Clin Neurol Neurosurg. 2015;132:74–78.
13. Saunders K, Merikangas K, Low NC, Von Korff M, Kessler RC. Impact of comorbidity on headache-related disability. Neurology. 2008;70:538–547.
14. Ashina S, Serrano D, Lipton RB, Maizels M, Manack AN, Turkel CC, et al. Depression and risk of transformation of episodic to chronic migraine. J Headache Pain. 2012;13:615–624.
15. Breslau N, Lipton RB, Stewart WF, Schultz LR, Welch KM. Comorbidity of migraine and depression: Investigating potential etiology and prognosis. Neurology. 2003;60:1308–1312.
16. Bigal ME, Lipton RB. Clinical course in migraine: Conceptualizing migraine transformation. Neurology. 2008;71:848–855.
17. Lakhan SE, Avramut M, Tepper SJ. Structural and functional neuroimaging in migraine: Insights from three decades of research. Headache. 2013;53:46–66.
18. Maizels M, Aurora S, Heinricher M. Beyond neurovascular: Migraine as a dysfunctional neurolimbic pain network. Headache. 2012;52:1553–1565.
19. McIntyre RS, Konarski JZ, Wilkins K, Bouffard B, Soczynska JK, Kennedy SH, et al. The prevalence and impact of migraine headache in bipolar disorder: Results from the Canadian Community Health Survey. Headache. 2006;46:973–982.
20. Jette N, Patten S, Williams J, Becker W, Wiebe S. Comorbidity of migraine and psychiatric disorders: A national population-based study. Headache. 2008;48:501–516.
21. Sharma K, Remanan R, Singh S. Quality of life and psychiatric comorbidity in Indian migraine patients: A headache clinic sample. Neurol India. 2013;61:355–359.
22. Buse DC, Silberstein SD, Manack AN, Papapetropoulos S, Lipton RB. Psychiatric comorbidities of episodic and chronic migraine. J Neurol. 2013;260:1960–1969.
23. Merikangas KR, Stevens DE. Comorbidity of migraine and psychiatric disorders. Neurol Clin. 1997;15:115–123.
24. Steel Z, Marnane C, Iranpour C, Chey T, Jackson JW, Patel V, et al. The global prevalence of common mental disorders: A systematic review and meta-analysis, 1980–2013. Int J Epidemiol. 2014;43:476–493.
25. Wacogne C, Lacoste JP, Guillibert E, Hugues FC, Le Jeunne C. Stress, anxiety, depression and migraine. Cephalalgia. 2003;23:451–455.