The impact of anxiety and depression on migraine patients’ journey to a tertiary headache center

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 first 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 first 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. Nonpharmacological 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.