Children and adolescents with migraine are about twice as likely to have an anxiety or depressive disorder as those without migraine, results from a review and meta-analysis suggest. The researchers described as “shocking” the fact that there were no previous studies of the association between migraine and trauma.
“This is compelling, high-level evidence showing there’s this established comorbidity between migraine and anxiety and depressive symptoms and disorders in this age group,” co-investigator Dr Serena Orr, a paediatric neurologist and headache specialist at Alberta Children’s Hospital and assistant professor in the Department of Paediatrics, University of Calgary, Canada, told Medscape Medical News.
The results “should compel every clinician seeing a child or adolescent with migraine to screen for anxiety and depression and to manage that if it’s present. That should be the standard of care with this level of evidence,” she said.
The findings were presented at the American Headache Society (AHS) Annual Meeting 2022.
Incidence divergence
Previous studies have suggested that 10% to 20% of children and adolescents will experience migraine at some point before adulthood, with the prevalence increasing after puberty.
While the female-to-male ratio is about 1:1 before puberty, there is a “big divergence in incidence curves” afterward ― with the female-to-male ratio reaching 2-3:1 in adulthood, Orr noted. Experts believe hormones drive this divergence, she said, noting that male adults with migraine have lower testosterone levels than male adults without migraine.
Orr and her colleagues were keen to investigate the relationship between child migraine and anxiety symptoms and disorders, as well as between child migraine and depression symptoms and disorders. They searched the literature for related case-control, cross-sectional, and cohort studies with participants of ages up to 18 years.
The researchers selected 80 studies to include in the review. Most of the studies had been carried out in the past 30 to 40 years. Both community-based and clinical studies were included.
Of the total, 73 studies reported on the association between the exposures and migraine, and 51 were amenable to quantitative pooling.
Results from a meta-analysis that included 16 studies that compared children and adolescents who had migraine with their healthy peers showed a significant association between migraine and anxiety symptoms (standardised mean difference [SMD], 1.13; 95% CI, 0.64 – 1.63; P < .0001).
Compared with children who did not have migraine, those with migraine had almost twice the odds of an anxiety disorder in 15 studies (odds ratio [OR], 1.93; 95% CI, 1.49 – 2.50; P < .0001).
In addition, there was an association between migraine and depressive symptoms in 17 relevant studies (SMD, 0.67; 95% CI, 0.46 – 0.87; P < .0001). Participants with vs without migraine also had higher odds of depressive disorders in 18 studies (OR, 2.01; 95% CI, 1.46 – 2.78; P < .0001).
Effect sizes were similar between community-based and clinic studies. Orr said it is important to note that the analysis wasn’t restricted to studies with “just kids with really high disease burden who are going to naturally be more predisposed to psychiatric comorbidity”.
‘Shocking’ lack of research
The researchers were also interested in determining whether having migraine along with anxiety or depression symptoms or disorders could affect headache-specific outcomes and whether such patients’ conditions would be more refractory to treatment. However, these outcomes were “all over the place” in the 18 relevant studies, Orr reported.
“Some looked at headache frequency, some at disability, some at school functioning; so, we were not able to put them into a meta-analysis,” she said.
Only two studies examined whether anxiety or depression earlier in childhood predisposes to subsequent migraine, and so that issue is still unresolved, Orr added.
The investigators also assessed whether outcomes with migraine are similar to those with other headache types, such as tension-type headaches. “We did not find a difference at the symptom or disorder level, but there were fewer of those studies” – and these, too, were heterogeneous, she said.
The researchers did not find any studies of the association between migraine and trauma, which Orr said was “shocking”.
“In the broader paediatric chronic-pain literature, there’s research showing that having a trauma or stress-related disorder is associated with more chronic pain and worse chronic pain outcomes, but we could not find a study that specifically looked at that question in migraine,” she added.
Emerging evidence suggests there may be a bidirectional relationship between migraine and anxiety/depression, at least in adults. Orr said having these symptoms appears to raise the risk for migraine, but whether that’s environmental or driven by shared genetics isn’t clear.
Experiencing chronic pain may also predispose individuals to anxiety and depression, “but we need more studies on this”.
In addition to screening children with migraine for anxiety and depression, clinicians should advocate for better access to mental health resources for patients with these comorbidities, Orr noted.
She added that a limitation of the review was that 82.5% of the studies reported unadjusted associations and that 26.3% of the studies were of low quality.
MedicalBrief was unable to access the review at the time of going to production.
Medscape article – Children with migraine at high risk of comorbid anxiety, depression (Open access)
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