Affiliations
doi: 10.29271/jcpsppg.2025.01.107ABSTRACT
Objective: To determine the prevalence of depression among patients with migraine presenting to the outpatient department of a tertiary care hospital.
Study Design: A descriptive cross-sectional study.
Place and Duration of the Study: Department of General Medicine, Combined Military Hospital, Rawalpindi, Pakistan, from October 2024 to March 2025.
Methodology: A total of 319 migraine patients of both genders aged between 18 and 70 years were included using a non-probability convenience sampling technique. Data were collected via an interviewer-based questionnaire. The first section of the questionnaire included demographic and clinical information. The second section utilised the Patient Health Questionnaire-9 (PHQ-9) to assess depressive symptoms. A PHQ-9 score of ≥5 was considered positive for depression. Descriptive statistics were applied for quantitative and categorical variables. The Chi-square test assessed associations between depression and clinical features. SPSS version 23 was used for analysis, with a value of p <0.05 considered statistically significant.
Results: Out of 319 patients, 180 (56.4%) were female and 139 (43.6%) were male, with a mean age of 33.62 ± 10.20 years. Depression was present in 231 (72.4%) participants: 64 (20.01%) had mild, 78 (24.45%) moderate, 38 (11.9%) moderately severe, and 51 (16.0%) had severe depression. Significant associations were found between depression and both migraine duration (p = 0.008) and frequency of attacks (p = 0.002).
Conclusion: Migraine sufferers had a notably high rate of depression, suggesting a significant connection between the two conditions and highlighting the need for routine screening and early referral to improve outcomes.
Key Words: Mental health, Migraine, Depression, PHQ-9, Screening.
INTRODUCTION
Migraine is a common and often disabling neurological dis- order affecting approximately 15% of the global population. According to the Global Burden of Disease Study, migraine is the second most prevalent neurological condition worldwide and is responsible for more years lived with disability than all other neurological disorders combined.1
The American Migraine Prevalence and Prevention study reported that 43% of women and 18% of men had a cumulative incidence of lifetime migraines, which is slightly lower than more recent data indicating that women are 3.25 times more likely than men to experience migraines.2
Migraine is generally categorised into two common subtypes: migraine with aura and migraine without aura. The most typical sign of migraine without aura is a unilateral throbbing headache of varying intensity, typically lasting 4 to 72 hours, and often aggravated by physical activity.3
Psychiatric comorbidity, particularly anxiety and depression, is frequently associated with migraine.4 These conditions may act as both triggers for migraine episodes and as psychological responses to chronic migraine.5
The relationship is believed to be bidirectional, with each condition increasing the risk of the other.6 Migraine can significantly impact everyday activities, increase medical expenses, cardiovascular risks, and lower the health-related quality of life (HRQoL).7 Psychiatric disorders increase the risk of developing a migraine into a chronic migraine.8
Depression, another major public health concern in Pakistan, has an estimated prevalence of 34% in adults, with higher rates observed among women and individuals with chronic illnesses.9 Depression is also common in primary care populations, with a prevalence of 30-45%.10 In a study conducted in Taiwan, 57% of the patients with transformed migraine showed psychological comorbidity, including major depression.11
Although migraine and depression are both highly prevalent conditions with significant individual and societal burden, the overlap between the two remains under-recognised in routine clinical practice. Most existing studies have either been conducted on Western populations or in specialised neurology clinics, whereas data from the general outpatient department in tertiary care hospitals of Pakistan are scarce. Furthermore, while depression is known to complicate the course of migraine, routine screening for depression among patients presenting with migraine is not standard practice in this study’s setting.
This study aimed to determine the frequency of depression among patients with migraine presenting to a tertiary care hospital in Pakistan. By explicitly quantifying this comorbidity in a local context, it aims to highlight the need for routine screening and early management, which may improve both neurological and psychiatric outcomes.
METHODOLOGY
This descriptive cross-sectional study was conducted in the Department of General Medicine, Combined Military Hospital, Rawalpindi, Pakistan, from October 2024 to March 2025, after obtaining approval from the Institutional Review Board of Combined Military Hospital, Rawalpindi, Pakistan. A sample size of 319 was calculated based on an anticipated depression prevalence of 70.6% in patients with migraine, as reported in a previous study by Ziaullah et al.,12 with a confidence level of 95% and a 5% margin of error.
All patients were selected by a non-probability convenience sampling technique. All patients gave their informed consent prior to inclusion in the trial.
This study included patients aged 18 to 70 years, of either gender (male or female), with migraine with or without aura, with the diagnosis of migraine confirmed by a consultant physician based on the criteria of the International Classification of Headache Disorders (ICHD),3 and experiencing at least two migraine attacks per month for the past two months.
Patients with other primary headache disorders, such as tension-type headache and cluster headache, were excluded. Patients with a previous history of psychiatric illness other than depression (e.g., anxiety, bipolar disorder, and psychosis), or currently using antidepressant medications, or those suffering from serious systemic conditions such as chronic renal disease, cardiovascular disease, or uncontrolled diabetes, were excluded.
All of the information was gathered via an interviewer-based questionnaire. All participants were explained the goal and procedure of the study by the study’s primary investigator. Data for this study were gathered using a well-standardised two- section questionnaire. The questionnaire's initial part asked about the participants’ demographic information, including marital status, age, gender, level of education, duration of illness, and frequency of attacks per month. In the second segment, the questions were about the Patient Health Questionnaire (PHQ-9),13 which was used to assess the depressive symptoms. Depression severity was classified using PHQ-9 as follows: a score of 5–9 indicated mild depression, 10–14 indicated moderate depression, 15–19 indicated moderately severe depression, and 20–27 indicated severe depression.13 Depression was categorised as positive if its score was 5 or more, and as negative otherwise.
Data were analysed using the Statistical Package of Social Sciences (SPSS) version 23.
Descriptive statistics were used for continuous variables (mean ± SD) and categorical variables (frequency, percentages). The Chi-square test was applied to determine the association between depression and categorical variables. A p-value of <0.05 was regarded as significant.
RESULTS
Out of 319 participants, 139 (43.6 %) were male and 180 (56.4 %) were female, with a mean age of 33.6 ± 10.2 years. A total of 169 (53.1%) participants had formal education, and 156 (48.9 %) were married. Regarding employment, 141 (44.2 %) participants worked in the private sector, 75 (23.5 %) in government service, and 103 (32.3 %) were unemployed. Most patients (n = 230, 72.1 %) had suffered from migraine for 2–3 months; 89 (27.9 %) had a duration exceeding 3 months.
Migraine attacks occurred 2–3 times per month in 213 (66.8 %) patients and 4–5 times per month in 106 (33.2 %). Migraine with aura was present in 105 (32.9 %) patients, and 214 (67.1 %) patients had migraine without aura (Table I).
Clinically significant depression was observed in 231 (72.4 %) patients, whereas 88 (27.6 %) had none (Figure 1). Among the 231 patients with depression, 64 (20.01%) had mild depression (PHQ-9 score 5-9), 78 (24.45%) had moderate depression (score 10-14), 38 (11.9%) had moderately severe depression (score 15-19), and 51 (16.0%) patients had severe depression (score 20-27). Depression correlated significantly with migraine duration (p = 0.008): 176/231 (76.1 %) of depressed patients had a duration of 2–3 months versus 55/231 (23.9 %) with > 3 months. A similar association was noted for attack frequency (p = 0.002), with 166/231 (71.9 %) of depressed patients reporting 2–3 monthly attacks compared with 65/231 (28.1 %) reporting 4–5 attacks per month (Table II).
Figure 1: Severity levels of depression in the study population (n = 319).
Table I: Baseline characteristics of the participants (n = 319).
| Variables | Categories | Frequencies (n) | Percentages (%) |
|
Age (years) |
Mean |
33.6 ± 10.2 |
- |
|
Gender - |
Male |
139 |
43.6 |
|
Female |
180 |
56.4 |
|
|
Educational status - |
Educated |
169 |
53.0 |
|
Uneducated |
150 |
47.0 |
|
|
Marital status - |
Married |
156 |
48.9 |
|
Unmarried |
113 |
35.4 |
|
|
Separated |
50 |
15.7 |
|
|
Employment status |
Government job |
75 |
23.5 |
|
- |
Private job |
141 |
44.2 |
|
Unemployed |
103 |
32.3 |
|
|
Duration of migraine |
2-3 months |
230 |
72.1 |
|
>3 months |
89 |
27.9 |
|
|
Frequency of attacks |
2-3 times/month |
213 |
66.8 |
|
4-5 times/month |
106 |
33.2 |
|
|
Type of migraine |
With aura |
105 |
32.9 |
|
- |
Without aura |
214 |
67.1 |
Table II: Association of depression with frequency and duration of migraine.
|
Variables |
Depression (n = 231) |
p-values |
|
|
Yes |
No |
||
|
Duration of migraine 2-3 months >3 months |
- 176 (76.2%) 55 (23.8%) |
- 54 (61.4%) 34 (38.6%) |
- 0.008 |
|
Frequency of migraine 2-3 times 4-5 times |
- 166 (71.9%) 65 (28.1%) |
- 47 (53.4%) 41 (46.6%) |
- 0.002 |
|
p-values were calculated using the Chi-square test. |
|||
DISCUSSION
This study sought to ascertain the prevalence of depression among patients with migraine who visited the outpatient department of a tertiary care hospital in the Northern Pakistan. The results revealed that the prevalence of depression among 319 individuals was 72.4%, indicating a high psychological burden in this population.
Previous studies have also documented an elevated risk of depression in patients with migraine. Breslau et al. discovered that patients with migraine had a threefold increased risk of depression in comparison to those without migraine.14
Patients with migraine who experience anxiety or depression are associated with greater psycho-social dysfunction, increased healthcare utilisation, financial burden, and significantly reduced HRQoL.15 These burdens emphasise the importance of screening for psychiatric comorbidities in patients with migraine.
This cross-sectional study comprised 319 individuals with migraine. Female participants were dominant in this study. Several factors, such as hormones, brain structure, genetic mutation or variation, life events, stress, and neuronal activity, may influence a female’s susceptibility to migraine through genetic and epigenetic pathways. These elements are all interrelated and have an impact on each other.16
Marital status and education level of participants were also explored in this study. This study observed a slightly higher prevalence among married individuals which was 48.9%. Although some studies suggest that social support from a spouse may mitigate migraine-related stress, Wilkins et al. reported mixed findings on the association between marital status and migraine prevalence.17
Education status revealed that 53% of migraine sufferers were educated. In a study conducted in the Western countries, Hagen et al. suggested that individuals with higher education may be more health aware and thus more likely to seek medical care for migraine symptoms.18
This study found that private sector employees constituted 44.2% of the sample, followed by unemployed individuals (32.3%) and government employees (23.5%). Employment stress has long been recognised as a significant trigger and a perpetuating factor for migraine, as shown by Spierings et al.19
Depression was found in 72.4% of migraine patients. These results are comparable to the prior studies carried out in Pakistan.12,20 In a study comprising participants over 65 years, Wang et al. found that migraine patients had a higher incidence of depression compared to non-migraine patients.21 According to another study by Lipton et al., patients with migraine had a greater risk of depression.22
Aura was present in 32.9% of the participants. These results are comparable to the American Migraine study reported by Lipton et al., where approximately 25-30% of migraine patients had aura, and 63.9% had migraine without aura.23
Numerous studies have shown that people who get migraine attacks frequently are more prone to experience depression.24 Moreover, migraine chronicity was associated with depression.25
This study has several strengths, such as being one of the first conducted in a local outpatient setting with an adequate sample size and the use of a validated tool (PHQ-9) for assessing depression. However, certain limitations should be acknowledged, such as the inclusion of migraine patients from only one tertiary care facility and the absence of a control group consisting of individuals without migraine, which restricts the generalisability of these findings. Due to the descriptive cross-sectional design of the study, these findings reflect prevalence and associations but do not establish causality. Other psychological conditions such as stress, anxiety, and bipolar disorder, as well as migraine triggers, such as dietary factors or sleep disturbances were not evaluated. Policies promoting the use of tools such as PHQ-9 and multidisciplinary care are needed. Future multi-centre and longitudinal studies should explore causality and the role of migraine triggers.
CONCLUSION
This study found a high prevalence of depression among migraine patients, indicating a significant association between the two conditions. This distribution reflects a considerable mental health burden that directly impacts quality of life and potentially worsens migraine outcomes. It emphasises the need for a routine psychological assessment in clinical practice. These findings are consistent with international evidence and highlight the importance of mental health screening.
ETHICAL APPROVAL:
Ethical approval was obtained from the Institutional Review Board of Combined Military Hospital, Rawalpindi, Pakistan (Letter No: 853; dated: 17 April 2024) prior to the initiation of the study.
PATIENTS’ CONSENT:
Informed consent was taken from all patients.
COMPETING INTEREST:
The authors declared no conflict of interest.
AUTHORS’ CONTRIBUTION:
SSK: Write-up of the manuscript, data acquisition, and formal analysis.
MNQ: Supervision, guidance, and critical revision of the manuscript.
FAS: Analysis, revision of the manuscript, and accountability.
FAJ: Interpretation, drafting, and analysis.
LS: Conception, drafting, and data acquisition.
HI: Interpretation, analysis, and revision.
All authors approved the final version of the manuscript to be published.
REFERENCES