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Keywords:

  • alexithymia;
  • anxiety;
  • depression;
  • migraine

Abstract

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Aims:  Some studies have found elevated alexithymia among patients with chronic pain, but the correlations between alexithymia and the severity of pain, depression, and anxiety among migraine patients are unclear. The aims of the present study were to investigate whether individuals suffering from episodic migraine (EM) differ from those with chronic migraine (CM) in regards to depression, anxiety, and alexithymia measures and to investigate the association of alexithymia with the results of depression and anxiety test inventories and illness characteristics.

Methods:  A total of 165 subjects with EM and 135 subjects with CM were studied. The Beck Depression Inventory (BDI), State–Trait Anxiety Inventory (STAI), and Toronto Alexithymia Scale (TAS) were administered to all subjects. The correlation between alexithymia and sociodemographic variables, family history of migraine and illness characteristics (pain severity, frequency of episode, duration of illness) were evaluated.

Results:  Compared with EM patients, the CM patients had significantly higher scores on measures of depression but not alexithymia and anxiety. There was a positive correlation between TAS scores and age and education in both migraine groups, but there was no correlation between TAS scores and other demographic variables. Depression and anxiety were significantly correlated with alexithymia in both migraine groups.

Conclusion:  Our results indicate that CM patients are considerably more depressive than EM patients. In this study, depression and anxiety were significantly correlated with alexithymia in both migraine groups. Our results demonstrate a positive association between depression, anxiety, and alexithymia in migraine patients.

THE MOST WIDELY studied affect/pain correlation is that between depression and pain.1–3 Reviews concerning the subject have concluded that people suffering from migraines experience symptoms of depression and are diagnosed with depression at a higher rate than the general population and matched controls.3–5 Similarly, previous researches have shown that anxiety levels and anxiety disorders are higher among those suffering from migraines relative to the general population.6–9 There are two putative explanations for the association of migraine and anxiety/depression10: (i) the same underlying etiological factors are common with both migraines and anxiety/depression; and (ii) there is a causative relation between migraines and anxiety/depression. A comprehensive model of migraines cannot exclude the role of psychological factors either as precipitants or an underlying diathesis.11

Although the correlations between depression and headaches and those between anxiety and headaches are well established, research examining the correlation between alexithymia and pain conditions including headaches is sparse.2,12,13 Sifneos used the term alexithymia to describe a striking paucity of fantasies and a utilitarian way of thinking.14 Alexithymia is a personality variable incorporating difficulty in identifying and describing feelings, difficulty in distinguishing between feelings and the physical sensation of emotional arousal, limited imaginal processes, and an externally oriented cognitive style.15,16 It was initially used to denote an adaptive style creating a tendency to develop psychosomatic symptoms.17,18 The Toronto Alexithymia Scale (TAS) is used to measure alexithymia and may prove useful in testing the construct with psychiatric and medical patient populations.14 Also the Revised Toronto Alexithymia Scale (TAS-R) demonstrated good internal consistency and a stable and replicable two-factor structure that is congruent with the two major dimensions of the alexithymia construct. Criterion validity was demonstrated by the ability of TAS-R scores to discriminate between behavioral medicine outpatients who were designated as alexithymic and those who were designated as non-alexithymic on the basis of clinical interview ratings. The previous reports show a relatively high correlation bewteen depression and alexithymia; however it is unclear whether alexithymia is a feature that is related to depression or is a distinct concept.19 Alexithymia was also found to be elevated in numerous psychosomatic, psychiatric, and medical conditions.20–23 Some authors have claimed that alexithymia is common in migraine and other headache patients. Muftuoglu et al. studied alexithymic features and affective states in migraine patients and found that migraine patients were significantly more depressive, anxious, and alexithymic than the control group. Also Yucel et al. studied depression and alexithymia in patients with tension-type headache. They found that compared to healthy controls, the subjects with headaches had significantly higher scores on measures of depression and alexithymia.24 However, to date, a clear correlation between alexithymia and migraine has not been established.25

The International Headache Society's ‘International Classification of Headache Disorders’ (2nd Edition) defines CM as, ‘Migraine headaches occurring on 15 or more days per month for more than 3 months in the absence of medication overuse’. The classification also notes that CM usually arises as a complication of EM.23,26–28 One must bear in mind that there are substantial individual differences in pain severity and disability among those with migraine.29,30 Psychological abnormalities found in migraine patients can be related to the degree of pain. More frequent headache attacks may be related to alexithymia. To investigate alexithymic features in migraine patients, it is essential to compare migraine patients with differential headache frequencies after controlling for the pain measures.

Therefore, this study had three primary goals. First, we examined whether individuals suffering from EM differ from those suffering from CM in regards to depression, anxiety and alexithymia measures. The second aim was to investigate the correlations between alexithymia and depression and anxiety. We also examined the symptoms across both groups. Third, we wanted to see whether alexithymia may be associated with migraines independent of pain variables. To our knowledge, this is the first study on record that compares EM and CM patients with respect to alexithymia.

METHODS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Participants

The study was conducted at the neuropsychiatry outpatients' clinics of Kocaeli University, Faculty of Medicine in Turkey. Participants were adults diagnosed with CM and EM (of at least 6 months' duration) who were identified following the classification of the International Headache Society. The study was conducted between 2006 September and 2007 February. The study respected the guidelines of the Helsinki declaration concerning medical research on humans. In addition, patients' written consent for the study was obtained. All patients were provided with a demographic and medical history survey as well as a set of questionnaires that included measures of alexithymia, anxiety, and depression. Pain intensity was measured with the Visual Analog Scale (VAS), which recorded headache case report forms for each patient.

A total of 319 patients were identified as meeting study eligibility criteria and were contacted for recruitment. Patients under 18 years of age and those with dementia, psychosis, chronic diseases or mental retardation were not recruited for this study. Six patients were excluded for these reasons (1.9%). Also, eleven patients (3.4%) declined to participate, and two patients who partially completed the questionnaires were excluded (0.6%), leaving a final sample of 300 patients.

Chronic Migraine Group

All patients who were suffering from CM, according to the revised International Classification of Headache Disorders (ICHD-II) criteria, were admitted to the outpatients' clinic of the University Hospital of Kocaeli, Turkey. All the subjects with migraines both with and/or without aura were included. According to these criteria, 135 patients (45%) diagnosed with CM were included in the study.

Episodic Migraine Group

All patients suffering from migraines with and/or without aura according to the ICHD-II criteria were admitted to the outpatient clinics. Patients who suffered from migraine with aura alone were excluded. According to these criteria, 165 patients (55%) diagnosed with EM with or without aura were included in the study.

Predictor measures

Toronto Alexithymia Scale

The TAS is a 20-item self-report scale with strong psychometric properties.14,30 Subjects were asked to indicate the extent to which they agreed or disagreed with each statement on a five-point Likert scale. The results are expressed as TAS-20 global scores, as well as three subscales measuring difficulty in identifying feelings and distinguishing them from bodily sensations of emotion (Factor 1), difficulty expressing feelings (Factor 2), and externally oriented thinking (Factor 3).

State–Trait Anxiety Inventory

The State–Trait Anxiety Inventory (STAI)31–32 has been used extensively in research with both adults and adolescents. STAI is a 20-item self-report scale for measuring state and trait anxiety. The State Anxiety scale (STAI-I) requires people to describe how they feel right now. The measures increase in response to situational stress and decline under relaxed conditions. The Trait Anxiety scale (STAI-II) asks people to describe how they generally feel, and reflects relatively stable individual differences in anxiety predisposition that are impervious to situational stress. The items are rated on a scale of 1–4. Total scores range from 20 to 80. The mean score (±SD) for working adult men is 34.89 ± 9.2, and that for working adult women is 34.79 ± 9.2. The STAI-I and STAI-II have high internal consistency and high test–retest reliability.33

The Beck Depression Inventory

The Beck Depression Inventory (BDI) is a 21-item scale assessing the symptoms and experience of depression, and is scored by summing the responses. Each of the 21 items in this scale includes four different aspects to examine the patient's mood in the preceding week. This test was developed by Beck and associates in 1961 and has been used in large samples.34,35 The 1979 version of the BDI was translated into Turkish by Hisli in 1988.36

Visual Analog Scale

The VAS consists of a 10-cm line that visually represents two behavioral extremes at both ends of a continuum: the scale ranges from no pain (score = 0) to extreme pain (score = 10).

Statistical evaluation

Data collected from medical records were recorded and entered into a database. In all calculations, the spss (version 11.0) program was used. Descriptive values were calculated (mean ± SD) for continuous variables and frequencies (numerical and percentage) for categorical variables. The Student's t-test was used for the comparison of the levels of the categorical variables (gender and family history of migraine) regarding TAS. Pearson's correlation analysis was used to determine Pearson univariate correlations between continuous variables (age, duration of education, duration of illness, frequency of migraine attacks, anxiety, pain, depression and alexithymia) in the total sample. Multiple binary logistic regression analyses were used for correlations between groups and risk factors (age, gender, education, and duration of the illness, family history of migraine, pain severity, state anxiety, trait anxiety, symptoms and experience of depression, alexithymia). However, the frequency of migraine attacks was used for the classification of groups. In all statistical analyses, significance was set at a P-value < 0.05.

RESULTS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

The study sample consisted of 300 adult EM and CM patients with or without aura. A total of 165 patients were diagnosed as having EM and 135 were diagnosed as having CM. There were 109 women (80.7%) and 26 men (19.3%) in the CM group; and 140 women (84.8%) and 25 men (15.2%) in the EM group. The mean age was similar in both groups (36.7 ± 12.6 in the EM group; 38.1 ± 15.3 in the CM group; = 0.141). All patients had at least a primary school education, the mean duration of education was 10.4 ± 3.9 years in the EM group and 9.7 ± 4.2 years in the CM group. The mean frequency of attacks was 6.1 ± 4.8 per month in the EM group and 29.3 ± 2.7 per month in the CM group (P < 0.0001).

Table 1 shows the demographics and clinical findings of all subjects with EM and CM.

Table 1.  The demographics and clinical findings of all subjects with episodic migraines and chronic migraines
VariablesEpisodic migraine (= 165)Chronic migraine (n = 135)Odds ratioP-value
  1. Episodic migraine patients were defined as patients with migraine headaches occurring less than 15 days per month for more than 3 months and chronic migraine patients were defined as patients with migraine headaches occurring on 15 or more days per month for more than 3 months.

Age (years)36.73 ± 12.6038.16 ± 15.320.9640.141
Duration of education (years)10.47 ± 3.919.71 ± 4.271.0480.154
Duration of illness (years)12.02 ± 9.5219.65 ± 9.9761.0380.013
Duration of attacks (hours)21.50 ± 35.02515.30 ± 14.2961.010.153
Male sex25 (15.2%)26 (19.3%)0.8700.688
Migraine in first-order relatives138 (83.6%)96 (71.1%)1.9380.034

According to multiple binary logistic regression analysis, sex and educational status were compatible between two groups (P = 0.688, P = 0.154, respectively). The mean duration of illness was 12 ± 9.5 years in the EM group and 9.6 ± 9.9 years in the CM group. The mean duration of illness was significantly higher in the EM group than in the CM group (P = 0.013). The mean duration of migraine attacks was 21.5 ± 35.0 h in the EM group and 15.3 ± 14.2 h in the CM group. The history of headaches similar to migraines occurring in first-degree relatives was reported by 83.6% of the patients (n = 96) from the EM group, and by 71% (n = 96) of patients from the CM group (P = 0.034) (Table 1).

Table 2 shows the results of multiple binary logistic regression analysis. The mean VAS score was 4.1 ± 2.3 in the EM group and the mean VAS score was 4.2 ± 2.2 in the CM group, which was also similar in both groups (P = 0.3). The mean (±SD) BDI scores of the EM and CM groups were 13.9 ± 8.5 and 16.9 ± 9.0, respectively. Patients with CM had a significantly higher mean BDI score than the EM patients (P = 0.019). Mean (±SD) STAI-I scores were 41.7 ± 6.4 in the EM patients and 40.79 ± 5.8 in the CM patients (= 0.211). Mean (±SD) STAI-II scores were 43.65 ± 6.1 in the EM patients and 44.52 ± 7.0 in the CM patients (= 0.166). Mean (±SD) TAS scores were 57.91 ± 14.43 in the EM patients and 59.29 ± 14.9 in the CM patients (= 0.714) (Table 2).

Table 2.  VAS, BDI, STAI-I, STAI-II and TAS scores of all subjects with Episodic migraine and Chronic migraine (comparison between groups)
VariablesMean ± SDOdds ratioP-value
Episodic migraine (= 165)Chronic migraine (n = 135)
  1. Episodic migraine was accepted as patients with migraine headache occurring less than 15 days per month for more than 3 months and Chronic migraine was accepted as patients with migraine headache occurring on 15 or more days per month for more than 3 months.

  2. BDI, Beck Depression Inventory; STAI-I, State–Trait Anxiety Inventory-State Anxiety; STAI-II, State–Trait Anxiety Inventory-Trait Anxiety; TAS, Toronto Alexithymia Scale; VAS, Visual Analog Scale.

Severity of migraine pain (VAS scores)4.15 ± 2.34.21 ± 2.250.9420.300
STAI-I scores41.76 ± 6.3740.79 ± 5.8211.0280.211
STAI-II scores43.65 ± 6.11744.52 ± 7.0050.9700.166
BDI scores13.87 ± 8.55616.94 ± 9.0620.6600.019
Total TAS scores57.91 ± 14.43659.29 ± 14.9291.0040.714

There were no significant differences between female and male patients with or without a history of migraine in regards to total TAS scores (P = 0.126; P = 0.704, respectively). Also, there was no correlation between TAS scores and sex or positive family history of migraine. There was a positive correlation between TAS scores and age. There was a negative correlation between TAS scores and education. In addition, there was a positive correlation between TAS scores and BDI, STAI-I and STAI-II scores. Frequency of the migraine attacks in the previous 6 months was positively correlated with BDI scores (= 0.179, P = 0.002). Frequency of the migraine attacks in the previous 6 months was not correlated with STAI-I, STAI-II or TAS (P = 0.104, P = 0.133 and P = 0.497, respectively) (Table 3).

Table 3.  Pearson's correlation coefficients between total TAS scores and continuous variables (significant values) in total sample (n = 300)
VariablesCorrelation coefficientP-value
  1. BDI, Beck Depression Inventory; STAI-I, State–Trait Anxiety Inventory-State Anxiety; STAI-II, State–Trait Anxiety Inventory-Trait Anxiety; TAS, Toronto Alexithymia Scale.

Age0.1450.012
Duration of education (years)−0.1280.027
Duration of illness (years)0.0700.224
Frequency of migraine attacks (monthly)0.0390.497
Duration of attacks (hours)0.0690.234
Intensity of migraine pain (VAS scores)−0.0770.183
STAI-I scores0.1280.027
STAI-II scores0.325<0.0001
BDI scores0.386<0.0001

DISCUSSION

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

This study has three major findings. First, CM and EM patients did not differ on alexithymic features. Second, these findings indicate that CM patients are considerably more depressive than EM patients. Third, in both groups, alexithymia was moderately to highly correlated with anxiety, depression, patient's age and education; however, alexithymia was not correlated with any of the pain measures.

Depression has been widely studied in both the chronic pain and alexithymia fields. Chronic pain is often comorbid with depression,16 and alexithymia is also substantially related to depression and may predispose to it.19 These observations suggest that depression may mediate the correlation between alexithymia and chronic pain. Also, concordant with our findings, Kirmayer and Robbins found alexithymia to be related to depressive symptoms, in addition to age and education.30 They proposed that depressive symptoms may make patients more reluctant to express their feelings because of the fear of potential rejection by others, which may result in limiting the patient's capability of recognizing and describing their own emotional state.30 Persistent and frequent headache attacks in CM patients may similarly precipitate the patient's illness worry and cause the patient to feel guilty. Studies have consistently found that frequent headache attacks are related to depression. This makes these patients more vulnerable to negative feedback from others, which then may be internalized. Therefore, it was suggested that more frequent headache attacks may have a relation with alexithymia and we tested this hypothesis. Wise et al. reported alexithymia as being best predicted by both depressed mood and lowered quality of life, rather than by the categorical ranking of the severity of the medical illness.37 In this study, there was no difference in the alexithymic features of EM and CM patients and alexithymia was not correlated with any of the pain measures that were in accordance with other studies.38,39 Affective disorders, particularly depression, are frequently reported in migraine patients.40,41However, alexithymia is still an understudied topic in migraine cases. Grabe et al. hypothesized that the difficulties in identifying feelings feature of alexithymia is highly predictive of a broad range of ‘state’ levels of psychopathology, particularly somatization.42 In this study, a high correlation was found between alexithymia scores and scores for anxiety and depression, which may indicate that alexithymia scores may be associated with psychological distress. Similarly, Muftuoglu et al. found that migraine patients are considerably more depressive, anxious and alexithymic than controls.25 Anxious subjects whose anxiety levels and psychological states fluctuate concomitantly in response to everyday stressors may perceive body sensations as more intense than non-anxious subjects do, who, because of a steadier emotional tone, have less autonomic fluctuation.2,7

Concordant with other study demographics, the patients in the EM group and CM group were mainly women in our study (84.8% and 80.7%, respectively).43,44 It has been reported that chronic daily headache carries a substantial genetic predisposition.45 Indeed, in our sample, a family history of migraine was found to be significantly high. Also, a family history of migraine was found significantly more often in the EM group (83.6%) than in the CM group (71.1%) (Table 1). In contrast, Ferrari et al. found a family history of migraine significantly more often in their CM than in their EM group.23 Many authors have studied the correlations between alexithymia and sociodemographic characteristics, as well as with depression and anxiety.10,37,46,47 In the present study, we found a positive correlation with age and a negative correlation with education. In contrast, Parker et al. and Muftuoglu et al. did not find a correlation between alexithymia and sociodemographic characteristics.25,48 They argued that treatment-seeking behavior may be more commonly associated with psychopathological conditions, and a hospital-based study group may influence the results. However, studies showed that irrespective of whether they had sought treatment or not for their headache problems, migraine patients reported higher levels of depression and physical symptoms than the control subjects.49,50

It should be noted that these results were obtained from a clinical sample of patients with migraines, and the results cannot be generalized to people with migraines in the community. We cannot comment on the difference between alexithymic features in migraine patients and healthy subjects because we did not recruit a healthy control sample. The present study was a cross-sectional study and none of the patients maintained a headache diary during the last 6 months. To stress the consistency, it certainly would be more enlightening to obtain the data from the patients' headache diaries. TAS has been modified twice, because the revised form, TAS-20, had eliminated the assessment of the paucity of fantasies component, which is one of the key factors of alexithymia as it was originally conceptualized by Sifneos.14 As the Turkish translation of TAS-20 was studied in the normative sample, we used TAS-20 for measuring alexithymia in the present study.31–32 To date TAS has not been translated into Turkish. Furthermore, it is difficult to describe how alexithymics would perform on the psychological test batteries, which mainly depend on verbal expression of feelings. In this regard, we suggest that, in addition to verbal communication, nonverbal interaction between the physician and the patient should be assessed carefully in clinical interventions. Further studies with healthy controls may give us more detailed information and a better understanding of the psychological dynamics and their involvement in clinical aspects in migraine patients.

In conclusion, the present results indicate that CM patients are considerably more depressive than EM patients and anxiety was significantly correlated with alexithymia in both migraine groups. Also, these results suggest a positive association between depression, anxiety and alexithymia in migraine patients.

Comorbid psychiatric disorders influence many factors including the prognosis of the current medical condition, severity of the symptoms, patient's compliance and the quality of the patient–doctor relationship. The results of this study show that the psychiatric evaluation of migraine patients is as important as the neurological evaluation.

REFERENCES

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES