Methodological limitations of anxiety screening tools used in migraine studies -a narrative review

Abstract

Background

Anxiety is commonly reported among patients with migraine, and anxiety questionnaires are frequently used to assess anxiety symptoms. This narrative review examines how common anxiety screening tools are applied in migraine studies and whether they are applied and interpreted appropriately.

Method

A PubMed search included studies using the Hospital Anxiety Depression Scale (HADS), Generalized Anxiety Disorder 7-Items (GAD-7) or Beck Anxiety Inventory (BAI). The search also included studies using the Hamilton Anxiety Rating Scale (HAM-A) or State Anxiety Inventory (STAI). Eligible patients were diagnosed with migraine according to the International Classification of Headache Disorders (ICHD-2 or ICHD-3).

Results

Ninety-eight studies met the inclusion criteria. In 42 studies (41%), an anxiety score above the cut-off was interpreted as an anxiety diagnosis. This approach was used in 52%, 44%, 41%, 29% and 38% of studies using HADS-A, GAD-7, BAI, HAM-A and STAI. Only three studies confirmed the diagnosis through a structured clinical interview. Data presentation and interpretation across the studies were heterogeneous. Only a few of the scales are validated in a population of migraine patients.

Conclusion

This study shows that anxiety screening tools are commonly used in migraine studies but with considerable variation in cut-off scores and interpretation. Such methodological differences and limited validation of these tools may make it difficult to determine the true prevalence of anxiety in migraine studies. Further studies are needed to validate these instruments and to establish clear guidelines for their use in migraine research.

Keywords

anxiety migraine hospital anxiety and depression scale generalized anxiety disorder 7 item scale beck anxiety inventory ham

Introduction

Migraine is a prevalent headache disorder affecting more than one billion people worldwide.¹ The one-year prevalence rate is approximately 10%, ranging from 4.5–6.0% in men and 14.5–18.0% in women.²

Migraine is a disorder that has been suggested to be strongly associated with a wide range of comorbidities, including psychiatric disorders such as anxiety and depression.^3–5 Studies of the relationship between migraine and anxiety have shown that patients with migraine are two to five times more likely to develop anxiety disorders compared to the general population.^6,7

In studies examining the comorbidity between migraine and anxiety, self-report anxiety screening forms are often used to assess the presence and severity of anxiety symptoms. However, some studies have used these tools to diagnose anxiety disorders by reporting the percentage of patients scoring above a certain cutoff point. This practice may misestimate the prevalence of anxiety, particularly when the questionnaires have not been validated for use in patients with migraine. Although such anxiety screening questionnaires can be practical tools for identifying anxiety, they are not sufficient for making a definitive diagnosis.⁸ According to national and international guidelines, a formal diagnosis should be made by a psychiatrist or a general practitioner.⁹ Reliance on a single questionnaire without clinical evaluation is inadequate for diagnosing anxiety disorders.^10,11 Instead, a two-stage approach, combining screening questionnaires with diagnostic interviews, can optimize resource use and provide more accurate prevalence estimates in patients with migraine.¹² Although anxiety screening tools are widely used in migraine research, their methodological application and interpretation have received limited critical evaluation. To our knowledge, very few studies have evaluated how these tools are applied and interpreted across migraine studies. Screening questionnaires are often used as measures for anxiety disorders, which may lead to misclassification and overestimation of psychiatric comorbidity. Therefore, this review aims to examine how the most common anxiety screening and assessment tools have been applied in migraine studies, and to assess whether they were used and interpreted correctly. Specifically, we investigated whether the use of screening scores led to the conclusion that patients had suffered from anxiety or symptoms of anxiety. Furthermore, we reviewed studies that combined screening questionnaires with diagnostic interviews. In the present study, we reviewed the Hospital Anxiety Depression Scale (HADS), Generalized Anxiety disorder Scale (GAD-7), Beck Anxiety Inventory (BAI), Hamilton Anxiety Rating Scale (HAM-A) and State-Trait Anxiety Inventory (STAI). Moreover, we compiled the studies that validated the different screening tools in patients with migraine.

Methods

The screening tools

Hospital anxiety and depression scale (HADS)

The Hospital Anxiety and Depression Scale (HADS) is a self-assessment tool developed to screen for anxiety and depression in outpatient settings and to measure the severity of emotional distress.¹³ The scale consists of 14 items, seven assessing anxiety (HADS-A) and seven assessing depression (HADS-D). The cut-off scores for the two subscales vary across studies, although a threshold of eight on each subscale is commonly used.¹⁴ One study reported that a cut-off score of eight or greater provided the optimal balance between sensitivity and specificity for HADS as a screening instrument for depression and anxiety, with both metrics averaging 0.80.¹⁵ One clinical-based study including 300 patients with migraine validated the HADS-D in this population.¹⁶ At a cut-off score of eight, the HADS-D had a sensitivity of 86.5%, a specificity of 86.5%, negative predictive value (NPV) of 95.0% and positive predictive value (PPV) of 68.2%. The area under the curve (AUC) was 0.92. It was further observed that higher cut-off scores were associated with decreased sensitivity but increased specificity. In contrast, a clinical study of 62 headache patients found that a cut-off score ≥13 was the most effective cut-off value for anxiety disorders, with a sensitivity of 84% and a specificity of 42%.¹⁷

Beck anxiety inventory (BAI)

The Beck Anxiety Inventory (BAI) is a self-report instrument developed to distinguish anxiety from depression.¹⁸ The BAI consists of 21 items, each rated by patients on a 0–4 scale, yielding a total score between 0 and 63. Both the original BAI and the revised BAI-II use this 21-item format, although cut-off scores for anxiety severity differ. For the BAI-I, scores of 0–9 indicate minimal anxiety, 10–18 mild anxiety, 19–29 moderate anxiety and 30–63 severe anxiety.¹⁹ For the BAI-II scores of 0–7 indicate minimal anxiety, 8–15 mild anxiety, 16–25 moderate anxiety and severe anxiety 26–63.²⁰ One study reported that the BAI demonstrated stronger convergent and discriminant validity than the State-Trait Anxiety Inventory.²⁰ While the BAI is not intended to establish a formal diagnosis of an anxiety disorder, it has been validated for assessing the presence and severity of anxiety symptoms and for screening probable cases of major anxiety disorders.¹⁹ To date, no studies have validated the BAI in patients with migraine.

Hamilton anxiety rating scale (HAM-A)

The HAM-A is used to assess the severity of anxiety symptoms in patients already diagnosed with an anxiety disorder according to DSM-5 or ICD-10. The HAM-A is administered by a trained clinician and consists of 14 items, each rated on a 5-point scale from 0 to 4. The total score is obtained by summing the individual item scores and ranges from 0 to 56. A score of <17 indicates mild anxiety, 18–24 indicates moderate anxiety and ≥25 indicates severe anxiety.²¹ To date, no studies have validated the use of the HAM-A in patients with migraine.

The generalized anxiety disorder 7 items (GAD-7)

The GAD-7 is a self-report questionnaire used to identify, and measure generalized anxiety disorder. The scale consists of seven items derived from the DSM-5. Each item is rated on a 4-point scale from 0 to 3, based on a symptom frequency over the previous two weeks.²² The total score ranges from 0 to 21. GAD-7 scores of 5, 10 and 15 indicate mild, moderate and severe levels of anxiety, respectively. The cut-off values vary across studies. One clinical study reported that a cut-off score ≥9 showed a sensitivity of 89% and a specificity of 82% for detecting GAD.²³ The optimal balance between sensitivity and specificity for the GAD-7 was achieved at a cut-off score ≥10.²³ Another clinical study that was conducted in health centers reported a sensitivity of 100% and a specificity of 83% at a cut-off score ≥9.²⁴ A separate clinical study evaluated 146 consecutive patients with migraine, assessing the performance of the GAD-7.²⁵ The study found that at a cut-off score of five, the GAD-7 demonstrated 78% sensitivity and a specificity of 75%, a positive predictive value (PPV) of 46.3% and a negative predictive value (NPV) of 92.4%. This study concluded that a cut-off score ≥5 provided the highest balance between sensitivity and specificity.

State-trait anxiety inventory (STAI)

The Spielberger State-Trait Anxiety Inventory (STAI) is a self-report questionnaire developed to distinguish two forms of anxiety, “state anxiety” and “trait anxiety”.²⁶ The scale consists of 40 items, divided into 20 separate items on each subscale. The STAI-State (STAI-S) measures state anxiety, defined as a temporary emotional response to a specific situation and characterized by tension and apprehensive thoughts.²⁷ In contrast, the STAI-Trait (STAI-T) reflects a more stable aspect of personality and a general tendency to experience anxiety across various situations.²⁸ Since migraine symptoms fluctuate over time, distinguishing between state anxiety and trait anxiety may be relevant. Each item is rated on a 4-point scale from 1–4, yielding a total score ranging from 20 to 80, with higher scores indicating greater anxiety. According to Spielberger, scores of 20–39 indicate low anxiety, 40–59 moderate anxiety and 60–80 high anxiety.²⁹ To date, no studies have validated the use of the STAI in patients with migraine.

Search strategy

This study was conducted as a narrative review aimed at critically examining how commonly used anxiety screening tools have been applied and interpreted in migraine. A targeted literature search was conducted in PubMed database and last updated on 27 March, 2025. Titles, abstracts, and full texts were screened by one author (M.Y.H.P.); no duplicate independent screening was performed. The purpose of the search was to identify studies that used one of the five selected anxiety screening tools for assessing the presence or severity of anxiety or anxiety symptoms in patients with migraine. The search strategy centered on key terms including: “migraine AND Generalized Anxiety Disorder (GAD-7)”, “migraine AND Beck Anxiety Inventory”, “migraine AND State-Trait Anxiety Inventory”, “migraine AND Hospital Anxiety and Depression scale (HADS)”, and “migraine AND Hamilton Anxiety Rating Scale”. Studies were grouped by screening instrument for narrative synthesis. A flow diagram illustrating the study selection process is presented in Figure 1.

Figure 1.

PRISMA flow chart diagram

Studies were included if they met following criteria:

Participants diagnosed with migraine according to the International Classification of Headache Disorders (ICHD-2 or ICHD-3).

Use of one of the five specified tools for anxiety.

Participants aged 18 years or older.

Studies were excluded if they met the following criteria:

Other headache types such as tension-type headache, vestibular migraine, post-traumatic headache or medication overuse headache.

Migraine patients with comorbid conditions such as traumatic brain injury or restless legs syndrome, except for overweight or obese patients.

Studies that did not include number or proportion of patients with a given cut-off score or the mean score from a screening tool.

Articles not available in English.

Data extraction

The initial search identified a total of 361 studies. After the removal of 48 duplicate records, 313 articles were screened by title and abstract. Sixty-seven (n = 67) articles were excluded due to a lack of focus on migraine and anxiety. A secondary full-text screening of 246 articles was conducted to determine eligibility. A total of 148 articles (n = 148) were then excluded according to the exclusion criteria. As a result, 98 studies were included (see figure 1). From the included studies, information was collected on the method of data collection, type of migraine diagnosis (episodic or chronic), the proportion of patients scoring above or below specific cut-off points, mean scores (if available) and the authors’ conclusions (i.e., whether anxiety or symptoms of anxiety were identified). In studies where the scores were presented but not interpreted by the authors, these were classed as “not discussed”. The following terms were considered inaccurate conclusions, if the authors did not specify that a diagnosis was made according to DSM or ICD-10 criteria: “anxiety”, “level of anxiety,” and “anxiety disorders”. Studies that compared the scores from the anxiety screening questionnaires with results from a diagnostic interview were not included in the tables. However, these data were discussed in the Discussion section. The majority of the studies did not report screening or prevalence scores for patients with and without aura. For this reason, these data were not extracted. The extracted data were organized into five separate tables, one for each screening instrument. In studies comparing multiple patient groups, only data from patients with migraine were included. In studies that reported pre-and post-treatment scores, only baseline values were considered. For studies that divided patients with migraine into subgroups, the overall mean score was calculated as the mean of subgroup means.

Results

The literature search yielded 361 articles, of which 98 were included. All articles before 2017 used the ICHD-2 to classify migraine. Fifty-eight articles published after 2018 used ICHD-3 to classify migraine. Nineteen articles used the International Headache Society (IHS) guidelines to classify migraine. The number of eligible studies applying HADS-A, BAI, HAM-A, GAD-7, and STAI to measure anxiety was 14 –16, respectively. The overall number of participants was 37,870, of whom 79% were women. Among them, 34% and 29% classified as chronic migraine and episodic migraine, respectively. The remainder (37%) had unknown migraine type or probable migraine. When interpreting the scores, the following terms were used: anxiety, level of anxiety, anxiety symptoms, anxiety scores, symptom score of anxiety, psychological distress and psychological burden. Overall, 41% of the studies concluded that participants had anxiety if they scored above a specified cut-off point (Tables 1 and 2).

Table 1.

Characteristics and application of anxiety screening tools in the included migraine studies.

Screening tools	Cut-off points	Interpretation	Variations/comments	References
HADS-A	≥8, ≥10 (12 studies), ≥7 (one study)	Indicates anxiety	Variation between ≥7- ≥10	^30–41
GAD-7	≥5, ≥ 10, ≥15	Mild, moderate and severe anxiety	One study used ≥10 to diagnose anxiety	⁴²
BAI	0–21 (low)	Anxiety severity level	Two studies used alternative ranges: of 0–7 indicated minimal anxiety symptoms, 8–15 points to mild, 16–25 moderate and 26–63 for severe anxiety. One study defined a score ≥ 21 as indicative of an anxiety disorder	^43–45
	22–35 (moderate)
	≥ 35 (severe)
STAI	< 30, (mild), 30–44 (moderate), ≥44 (severe)	State and trait anxiety	Alternative cut-off scores: ≥59 for STAI-T (severe anxiety), 20–80 scale divided into mild-very severe categories), ≥65 used to indicate high state and trait anxiety	⁸
HAM-A	8–14 (mild), 18–24 (moderate), ≥25 (severe)	Anxiety severity	Two studies used a cut-off score ≥7 to determine anxiety.	^46,47

Cut-off scores for anxiety measures used by the screening tools varied across studies (Table 3). HADS-A cut-offs ranged from 7–10. The GAD-7 applied 5,10 and 15 to indicate mild, moderate and severe anxiety. BAI, STAI and HAM-A used comparable categorical ranges.

Table 2.

Study Characteristics for each screening tool.

			CM	EM	Migraine type not specified/probable migraine	CM	EM	Migraine type not specified/probable migraine
	Number of studies included	Number of participants	Proportion of participants with CM and EM (%)			Mean score			Proportion of studies concluding “anxiety” (%)
	Number of studies included	Number of participants	CM	EM	Migraine type not specified/probable migraine	CM	EM	Migraine type not specified/probable migraine	Proportion of studies concluding “anxiety” (%)
HADS-A	29	11923	32	30	37	9.1 ±4.5	8.4±4.3	9.4 ±4.7	52
GAD-7	17	19399	36	40	24	9.9± 5.5	4.8±5.2	5.8± 5.5	44
BAI	22	3129	40	37	23	16.2 ±11.8	13.7 ±10.3	12.2 ±8.9	41
HAM-A	14	2074	34	16	50	18.1 ±7.2	13.9 ±6.8	13.3 ±8.9	29
STAI	16	1345	29	28	43	41.7± 8.7*	41.1± 8.8*	42.7 ±11.0*	38
STAI	16	1345	29	28	43	43.2±9.9**	42.0±8.9**	46.9 ±10.6**	38
Total	98	37870	34	30	36	N/A			41

*: STAI-S*; **: STAI-trait.

Table 3.

Study characteristics for the included studies using HADS-A.

Proportion of patients with HADS-A ≥ 8 (%)
Authors	Population (clinical or population-based)	Number of patients and sex proportion	Headache diagnosis (%ß) (CM/EM)	Mean anxiety score ± SD	Chronic migraine	Episodic migraine	Authors conclusion (differentiate btw. anxiety or symptoms of anxiety)
Wacogne, 2003 ³⁰	Clinical based	141(77)	100"	11 ± 3.8	N/A	N/A	Anxiety
Tomé-Pires, 2016 ⁴⁸	Clincal based	43(93)	100"	8.4 ± 3.4"	N/A	N/A	Anxiety
Yong, 2012 ³⁵	Clincal based	176(82)	CM: 30	6.5 ± 3.8	33	49	Anxiety symptoms
Yong, 2012 ³⁵	Clincal based	176(82)	EM: 70	6.5 ± 3.8	33	49	Anxiety symptoms
Lantéri-Minet, 2005 ⁴⁹	Population-based	1957(N/A)	100"	N/A	28"	N/A	Anxiety
Irimia, 2021 ³⁶	Population-based	468(90)	CM: 39	11.1 ± 4.1**	N/A	N/A	Anxiety symptoms
Irimia, 2021 ³⁶	Population-based	468(90)	EM: 61	9.2 ± 3.8*	N/A	N/A	Anxiety symptoms
Oedegaard, 2006 ⁵⁰	Population-based	6045 (72)	100"	N/A	9"	N/A	Anxiety
Rezaee, 2024 ³⁷	Clinical based	68(68)	EM:38	11.9 ± 4	N/A	N/A	Anxiety
Rezaee, 2024 ³⁷	Clinical based	68(68)	CM:62	11.9 ± 4	N/A	N/A	Anxiety
C. Prisnie, 2018 ³⁸	Clincal based	268 (80)	100"	7.6 ± 4.4	N/A	N/A	Anxiety symptoms
Ruscheweyh, 2019 ³⁹	Clinical based	128(91)	CM: 30 EM: 70	7.4 ± 3.9"	N/A	N/A	Not discussed
Palacios-Ceña, 2016 ⁵¹	Clincal based	103 (100)	CM: 51	*9. 4◊	N/A	N/A	Anxiety
Palacios-Ceña, 2016 ⁵¹	Clincal based	103 (100)	EM: 49	11. 2 **◊	N/A	N/A	Anxiety
Muñoz, 2016 ⁴⁰	Clincal based	155(86)	CM:67	6.4 ± 3.6/8.5 ± 4.5**	13†	18†	Anxiety
Muñoz, 2016 ⁴⁰	Clincal based	155(86)	EM:33	6.4 ± 3.6/8.5 ± 4.5**	13†	18†	Anxiety
Mathur, 2020 ⁵²	Clincal based	61(67)	CM: 100	N/A	77	N/A	Anxiety symptoms
Fernández-de-las-Peñas, 2018 ⁵³	Clincal based	72(100)	EM:100	12.3(11.7–12.8)"	N/A	N/A	Anxiety symptoms
Kucukdurmaz, 2018 ³²	Clinical based	69(100)	100"	13.4 ± 6.2"	49"	N/A	Anxiety
Kao, 2014 ³³	Clincal based	434(80)	100"	9.1 ± 4.5	N/A	N/A	Anxiety
Chu H.T, 2018 ⁴¹	Clinical based	49(68)	CM:16	9.0 ± 4.6**	N/A	N/A	Symptom score of anxiety
Chu H.T, 2018 ⁴¹	Clinical based	49(68)	EM:84	7.9 ± 4*	N/A	N/A	Symptom score of anxiety
Ghiggia, 2022 ⁴²	Clinical based	250 (100)	CM: 100	7. 9 ± 4.1**	N/ A	N/A	Psychologial distress
Dorado, 2023 ⁵⁴	Clincal based	57(71)	EM: 43	9(6–14) ^◊	N/ A	N/A	Anxiety
Dorado, 2023 ⁵⁴	Clincal based	57(71)	CM: 57	9(6–14) ^◊	N/ A	N/A	Anxiety
Barón, 2017 ⁵⁵	Clincal based	162(78)	EM: 53	6.8*◊	N/A	N/A	Level of anxiety
Barón, 2017 ⁵⁵	Clincal based	162(78)	M: 47	9.1** ◊	N/A	N/A	Level of anxiety
Alvarez-Astorga, 2021 ³⁴	Clinical based	96(83)	EM:30	8.2 ± 4.6**	27	17	Anxiety
Alvarez-Astorga, 2021 ³⁴	Clinical based	96(83)	CM:70	5.95. 4.5±*	27	17	Anxiety
Torrente, 2023 ⁴³	Clinical based	42(76)	100"	10.3 ± 4.8**	N/A	N/A	Anxiety symptoms
Hung, 2006 ⁴⁴	Clinical based	73(86)	EM: 71	14.9 ± 3.6*/15.2 ± 2.8	N/A	N/A	Anxiety symptoms
Hung, 2006 ⁴⁴	Clinical based	73(86)	CM: 29	14.9 ± 3.6*/15.2 ± 2.8	N/A	N/A	Anxiety symptoms
Lin, 2019 ⁴⁵	Clinical based	528 (66)	EM 82	7.7 ± 4*	N/A	N/A	Anxiety
Lin, 2019 ⁴⁵	Clinical based	528 (66)	CM: 18	8.5 ± 4.4	N/A	N/A	Anxiety
John, 2007 ³¹	Clinical based	65(75)	100"	10.8 ± 2.2	N/A	N/A	Anxiety score
Antonio, 2023 ⁵⁶	Clinical based	44(75)	EM:91	6.5 ± 4.9"	N/A	N/A	Anxiety symptoms
Antonio, 2023 ⁵⁶	Clinical based	44(75)	CM:9	6.5 ± 4.9"	N/A	N/A	Anxiety symptoms
Bertão, 2024 ⁵⁷	Clinical based	71(100)	100"	10 ± 6"	N/A	N/A	Anxiety
Mengi, 2024 ⁴⁶	Clinical based	33(100)	CM:100	8.6 ± 3.6	N/A	N/A	Anxiety symptoms
Rammohan, 2019 ⁴⁷	Clinical based	133(78)	100"	13.82 ± 2.72	N/A	N/A	Anxiety
Ahmed, 2021 ⁵⁸	Clincal based	60(100)	100"	11.6 ± 3.22	N/A	N/A	Anxiety
Total		11848(81)	EM: 30 CM: 32 “: 38	EM: 8.4 ± 4.3 CM: 9.1 ± 4.5 “: 9.4 ± 4.7

**=CM = chronic migraine; *=EM = episodic migraine; “ =migraine type not specified/probable migraine; † = HADS-A score ≥10; ◊ = median score.

Across studies using the HADS-A (Table 2), 11,848 participants were included: 27% had chronic migraine, 28% episodic migraine and 41% an unknown migraine or probable migraine type. The mean HADS-A scores were 9.1 ± 4.5, 8.4 ± 4.3 and 9.4 ± 4.7 for chronic migraine, episodic migraine and unknown/probable migraine, respectively. Twenty-two studies^30–4856 –58 reported a mean score and four studies^51,53–55 reported a median score range. Six studies^{34,37,40,43,47,58} (21%) reported the proportion scoring ≥8 and 15 studies^30,32–3437,40,45,47 –51,54,57,58 (52%) concluded that participants scoring above the cut-off point had anxiety.

In the studies using the BAI (Table 4), 3129 participants were included: 40% chronic migraine, 37% episodic migraine and 23% unknown migraine type or probable migraine. The mean BAI scores were 16.2 ±11.8, 13.7 ±10.3 and 12.2 ±8.9, respectively. Seventeen studies^4,58–73 reported mean scores and four studies^74–77 reported median values. Seven studies^{60,63,68,72–75} (32%) provided proportion within a range and nine studies (41%) reported that scores above the cut-off reflected anxiety.

Table 4.

Study characteristics for the included studies using BAI.

	Mean BAI score ± SD					Score (%)
Author	Population (clinical or population-based)	Number of patients and sex proportion	Headache diagnosis (%) (CM/EM)	Episodic migraine	Chronic migraine	8–15 mild	16–25 Moderate	26–63 severe	Authors conclusion (differentiate btw anxiety or anxiety symptoms)
Dikmen, 2017 ⁶¹	Clinical based	26(100)	EM: 65	14.0 ± 9.4"	N/A	N/A	N/A	N/A	Anxiety symptoms
Dikmen, 2017 ⁶¹	Clinical based	26(100)	CM:35	14.0 ± 9.4"	N/A	N/A	N/A	N/A	Anxiety symptoms
Martins, 2015 ⁶²	Clinical based	87(66)	EM:68	15.4 ± 12.8"	N/A	N/A	N/A	N/A	Anxiety symptoms
Martins, 2015 ⁶²	Clinical based	87(66)	CM:32	15.4 ± 12.8"	N/A	N/A	N/A	N/A	Anxiety symptoms
İnci, 2023 ⁵⁹	Clinical based	114(87)	100"	15.4 ± 9.1"	N/A	N/A	N/A	N/A	Anxiety
Llop, 2016 ⁶³	Population-based	162(87)	EM: 100	10.0 ± 7.3	N/A	13*	19**	10***	Anxiety symptoms
Kim, 2014 ⁶⁴	Clinical-based	251(71)	EM: 73	12.6 ± 10	18.9 ± 12.6	N/A	28†	N/A	Anxiety
Kim, 2014 ⁶⁴	Clinical-based	251(71)	CM: 27	12.6 ± 10	18.9 ± 12.6	N/A	28†	N/A	Anxiety
Tietjen, 2008 ⁶⁰	Clinical-based	721 (88)	EM: 65	N/A	N/A	38	19	13	Anxiety
Tietjen, 2008 ⁶⁰	Clinical-based	721 (88)	CM:35	N/A	N/A	38	19	13	Anxiety
Şahin 2024 ⁶⁵	Population-based	164(84)	CM: 100	N/A	22.4 ± 10.6	N/A	N/A	N/A	Anxiety symptoms
Saçmacı, 2020 ⁷⁷	Clinical-based	106(N/A)	EM: 58	11(4–21)^◊	18 (10–24) ◊	N/A	N/A	N/A	Anxiety symptoms
Saçmacı, 2020 ⁷⁷	Clinical-based	106(N/A)	CM:42	11(4–21)^◊	18 (10–24) ◊	N/A	N/A	N/A	Anxiety symptoms
Cengiz, 2019 ⁷⁸	Clinical-based	54(83)	EM:100	17.5 ± 12.8	N/A	N/A	N/A	N/A	Anxiety
Demiryurek 2016 ⁶⁷	Clinical-based	60(73)	CM:100	N/A	13. 8 ± 9.2	N/A	N/A	N/A	Anxiety
Delussi, 2024 ⁶⁸	Clinical-based	202(62)	100"	14.7 ± 5	N/A	N/A	N/A	N/A	Anxiety
Ertem, 2020 ⁶⁹	Clinical-based	30(100)	EM 60	19.9 ± 14.7	19.8 ± 12.3	N/A	N/A	N/A	Anxiety symptoms
Ertem, 2020 ⁶⁹	Clinical-based	30(100)	CM: 40	19.9 ± 14.7	19.8 ± 12.3	N/A	N/A	N/A	Anxiety symptoms
Aydinlar, 2024 ⁷⁴	Clinical-based	54(91)	EM:44	9(4–22.5)	N/A	76	17	7.5	Anxiety
Aydinlar, 2024 ⁷⁴	Clinical-based	54(91)	CM:56	9(4–22.5)	N/A	76	17	7.5	Anxiety
Minen, 2014 ⁴	Clinical-based	225(79)	100"	5.4 ± 5.2"	N/A	N/A	N/A	N/A	Anxiety symptoms
Duarte, 2015 ⁷⁹	Clinical-based	49(94)	EM: 71	16.3 ± 12.9"	N/A	NA	N/A	N/A	Anxiety scores
Duarte, 2015 ⁷⁹	Clinical-based	49(94)	CM: 29	16.3 ± 12.9"	N/A	NA	N/A	N/A	Anxiety scores
Santiago, 2014 ⁷¹	Population-based	60(88)	CM:100	N/A	15.5 ± 12.9	N/A	N/A	N/A	Not discussed
Aydinlar, 2024 ⁷⁵	Clinical-based	72(92)	CM: 100	N/A	12(6.5–19)	N/A	N/A	N/A	Anxiety
Kozak, 2016 ⁷⁰	Clinical-based	55(85)	100"	20.2 ± 11.4	N/A	N/A	N/A	N/A	Anxiety symptoms
Matei, 2015 ⁷²	Clinical-based	27(100)	100"	20.4 ± 12.4	N/A	N/A	N/A	N/A	Anxiety symptoms
Metin, 2023 ⁷⁶	Clinical-based	20(100)	CM: 100	N/A	21 (14.5–28) ^◊	N/A	N/A	N/A	Anxiety symptoms
Esmael, 2021 ⁸⁰	Clinical-based	120(74)	CM:100	N/A	7.4 ± 6.2	N/A	N/A	N/A	Anxiety symptoms
Ocal, 2024⁷³	Clinical-based	531(70)	EM: 100	N/A	N/A	32	21	14	Anxiety
Total	3219(81)		EM: 37	EM: 13.7 ±10.3
			CM: 40	CM: 16.2 ±11.8
			“: 23	“: 12.2± 8.9

CM = chronic migraine; EM = episodic migraine; “ = migraine type not specified/ probable migraine; N/A = not applicable; ^◊ = median score; †= BAI score ≥21.

Among studies using the STAI (Table 5), 1345 participants were included: 28% chronic migraine, 29% episodic migraine and 43% unknown migraine type or probable migraine. STAI-S (state anxiety) mean scores were 41.7 ± 8.7, 41.1 ± 8.8, and 42.7 ± 11.0; STAI-T(trait anxiety) mean scores of were 43.2 ± 9.9, 42.0 ± 8.9 and 46.9 ± 10.6 Fifteen studies^8,81–94 reported mean scores, and one study⁵³ a median. Three studies^88,90,92 (19%) reported proportions within a range and six studies^{81,82,84,86,91,93} (38%) interpreted scores above a cut-off as anxiety.

Table 5.

Study characteristics for the included studies using STAI.

	Mean STAI-S* and STAI-trait ** ± SD							Score (%)
Author	Population (clinical or population- based)	Number of patients and sex proportion (n (%F))	Headache diagnosis (%) (CM/EM)	Episodic migraine		Chronic Migraine		(Mild) 20–39	Moderate (40–59)	Severe (60–80)	Authors conclusion (differentiate btw anxiety or anxiety symptoms)
Author	Population (clinical or population- based)	Number of patients and sex proportion (n (%F))	Headache diagnosis (%) (CM/EM)	STAI-S	STAI-T	STAI-S	STAI-T	(Mild) 20–39	Moderate (40–59)	Severe (60–80)
Demir, 2020 ⁸¹	Clinical based	30(80)	100"	39.9 ± 10.9*”	45.7 ± 9**”	N/A	N/A	N/A	N/A	N/A	Anxiety scores
Kowacs, 2003 ⁸	Clinical based	51(90)	100"	N/A	N/A	N/A	N/A	N/A	62	38	Anxiety symptoms
Kumar, 2021 ⁸²	Clinical based	20(55)	CM:100	N/A	N/A	52.0 ± 13.8*	55.7 ± 13.4**	N/A	N/A	N/A	Anxiety
Pistoia, 2022 ⁸³	Clinical based	130(100)	EM: 50	N/A	42.7 ± 8.6**	N/A	46.4 ± 12.2**	N/A	N/A	N/A	Anxiety symptoms
Pistoia, 2022 ⁸³	Clinical based	130(100)	CM: 50	N/A	42.7 ± 8.6**	N/A	46.4 ± 12.2**	N/A	N/A	N/A	Anxiety symptoms
Yalug, 2010 ⁸⁴	Clinical based	300(83)	EM:55	41.8 ± 6.4*	43.7 ± 6.12**	40.8 ± 5.8	44.5 ± 7**	N/A	N/A	N/A	Anxiety
Yalug, 2010 ⁸⁴	Clinical based	300(83)	CM: 45	41.8 ± 6.4*	43.7 ± 6.12**	40.8 ± 5.8	44.5 ± 7**	N/A	N/A	N/A	Anxiety
Zhang, 2012 ⁸⁵	Clinical based	27(74)	100"	43.5 ± 13.8*"	46.4 ± 12.9**"	N/A	N/A	N/A	N/A	N/A	Anxiety
Bag, 2005 ⁸⁶	Clinical based	75(27)	100"	N/A	N/A	N/A	53.2 ± 8.1**"	N/A	N/A	N/A	Anxiety
Mongini, 2005 ⁸⁷	Clinical based	23 (100)	CM:100	N/A	N/A	40.39 ± 12.6*	44.8 ± 9.2**	N/A	N/A	N/A	Not dicsussed
D’Ippolito, 2017 ⁸⁸	Clinical based	11(55)	EM:100	46.5 ± 3.47*	43.2 ± 2.47**	N/A	N/A	N/A	N/A	N/A	Anxiety symptoms
Santangelo 2016 ⁸⁹	Clinical based	72(88)	100"	40.6 ± 11.6*"	42.1 ± 9.7	N/A	N/A	N/A	N/A	10†	Anxiety symptoms
Muñoz Gómez 2023 ⁹⁰	Clinical based	184(72)	EM: 61	44.3 ± 13.1*	41.1 ± 12.2**	41.7 ± 10.4*	37.5 ± 9.7**	16	39	45	Anxiety symptoms
Muñoz Gómez 2023 ⁹⁰	Clinical based	184(72)	CM:39	44.3 ± 13.1*	41.1 ± 12.2**	41.7 ± 10.4*	37.5 ± 9.7**	16	39	45	Anxiety symptoms
Petrovics-Balog, 2019 ⁹¹	Clinical based	123(88)	100"	39.4 ± 12.8*"	45.5 ± 10.7	N/A	N/A	N/A	N/A	N/A	Anxiety
Fernández-de-las-Peñas, 2018 ⁵³	Clinical based	72 (100)	EM:100	25.3(23.7–26.9) *”	21.8 (20.5–22.5) **^◊”	N/A	N/A	N/A	N/A	N/A	Anxiety symptoms
David, 2022 ⁹²	Clinical based	23(96)	CM:100	N/A	N/A	38.8 ± 7.4*	42.3 ± 12.0**	N/A	N/A	N/A	Anxiety symptoms
Muftuoglu, 2003 ⁹³	Clinical based	50(64)	100"	46.8 ± 8.3*	48.8 10.0**	N/A	N/A	N/A	N/A	N/A	Anxiety
Cassidy 2003 ⁹⁴	Clinical based	140 (100)	EM: 76	36.2 ± 1.3*	N/A	42 ± 2.3*	N/A	N/A	N/A	N/A	Psychologial burden
Cassidy 2003 ⁹⁴	Clinical based	140 (100)	CM:24	36.2 ± 1.3*	N/A	42 ± 2.3*	N/A	N/A	N/A	N/A	Psychologial burden
Total		1345 (73)	CM: 29	CM (): 41.7 ± 8.7 CM (*): 43.2 ± 9.9				16	51	32
			EM: 28	EM ():41.1 ± 8.8 EM (*): 42.0 ± 8.9
			“: 43	“ (): 42.7 ± 11.0 “ (*): 46.9 ± 10.6

CM = chronic migraine; EM = episodic migraine; “= Unknown/probable migraine; * = state anxiety; ** = trait anxiety; N/A = not applicable; ^◊ = median score; †= STAI-S and STAI-T ≥ 65.

For studies using the HAM-A (Table 6) 2074 participants were included: 34% with chronic migraine, 16% episodic migraine and 50% had unknown migraine or probable migraine. The mean scores were 18.1 ± 7.2, 13.9 ± 6.8, and 13.3 ± 8.9, respectively. All fourteen studies^{46,47,100,107–117} (100%) reported mean scores. Four studies^{98,101,105,106} (29%) reported proportion within a range and another four studies^{98,102,106,118} (29%) concluded that scores above the cut-off point indicated anxiety.

Table 6.

Study characteristics for the included studies using HAM-A.

	Mean HAM-A score ± SD					Score (%)
Author	Population (clinical or population-based)	Number of patients and sex proportion (n (%F))	Headache diagnoses (%) (CM*/EM/ PM***)	Episodic migraine	Chronic migraine	8–14 (mild)	18–24 Moderate	≥ 25 (severe)	Authors conclusion (differentiate btw. depression or symptoms of anxiety)
Mantonakis, 2024 ⁹⁵	Population-based	1328(81)	100”	14.1 ± 6.7	19.6 ± 7.7	N/A	70	12	Anxiety symptoms
Wu, 2018⁹⁶	Clinical-based	35(71)	CM: 43	7.8 ± 2.6	9.6 ± 3.6	N/A	N/A	N/A	Anxiety symptoms
Wu, 2018⁹⁶	Clinical-based	35(71)	EM: 57	7.8 ± 2.6	9.6 ± 3.6	N/A	N/A	N/A	Anxiety symptoms
Wei, 2022 ⁹⁷	Clinical-based	30(83)	100"	5.3 ± 1.3	N/A	N/A	N/A	N/A	Not discussed
Park, 2006 ⁷⁸	Clinical-based	24(67)	100"	27.5 ± 7.1	N/A	N/A	N/A	N/A	Anxiety symptoms
Zhu, 2022 ⁹⁸	Clinical-based	118(45)	CM:100	17 ± 4.2	N/A	N/A	N/A	N/A	Anxiety
Lo Buono, 2019 ⁹⁹	Clinical-based	100(N/A)	100"	10.2 ± 7.9"	N/A	N/A	N/A	N/A	Anxiety symptoms
Yang, 2022 ¹⁰⁰	Clinical-based	27(90)	EM:100	12.4 ± 8.7	N/A	N/A	N/A	N/A	Anxiety scores
Jiang, 2023 ¹⁰¹	Clinical-based	60(80)	100"	16.9± 3.9	N/A	N/A	N/A	N/A	Anxiety symptoms
Hrytsenko, 2023 ¹⁰²	Clinical-based	133(77)	100"	17.9± 5.9"	N/A	NA	N/A	N/A	Anxiety
Zhou, 2024 ¹⁰³	Clinical-based	55(69)	100"	5.4 ± 3.0	N/A	N/A	N/A	N/A	Not discussed
Onur, 2019 ¹⁰⁴	Clinical-based	14(64)	CM:100	N/A	26.8 ± 11.7	N/A	N/A	N/A	Anxiety symptoms
Silvestro 2022 ¹⁰⁵	Clinical-based	43(88)	EM:19	13 ± 9"	N/A	N/A	N/A	N/A	Anxiety symptoms
Silvestro 2022 ¹⁰⁵	Clinical-based	43(88)	CM:81	13 ± 9"	N/A	N/A	N/A	N/A	Anxiety symptoms
Karakurum, 2003 ⁴⁶	Clinical based	87(96)	EM:43	6.9 ± 7.6	11.9 ± 6.5	N/A	N/A	N/A	Anxiety
Karakurum, 2003 ⁴⁶	Clinical based	87(96)	CM:57	6.9 ± 7.6	11.9 ± 6.5	N/A	N/A	N/A	Anxiety
Russo, 2020 ¹⁰⁶	Clinical based	70(79)	CM: 100	N/A	17.1 ± 1.7	75	58	N/A	Anxiety
Total		2074 (70)	EM: 16	EM: 13.9 ± 6.8		75	64	12
			CM:34	CM: 18.1 ± 7.2
			“50	“: 13.3 ± 8.9

CM = chronic migraine; EM = episodic migraine; PM = probable migraine; “= migraine type not specified; N/A = not applicable

For studies using GAD-7 (Table 7) 19,399 participants were included: 40% chronic migraine, 36% episodic migraine, and 24% with unknown migraine or probable migraine type. The mean GAD-7 scores were 9.9 ± 5.5, 4.8 ± 5.2 and 5.8 ± 5.5 for chronic migraine, episodic migraine and unknown migraine type or probable migraine, respectively. Fourteen studies^{22,100,107–114}119 –122 reported mean scores, and two studies^115,116 reported median. Seven studies^{107,108,110,114,120–122} (39%) reported proportion within score range and eight studies^{108,110–112}116,120 –122 (44%) concluded that scores above a cut-off point indicated anxiety.

Table 7.

Study characteristics for the included studies using GAD-7

GAD-7
Author	Population (clinical or population-based)	Number of patients and sex proportion (n (%F))	Headache diagnosis (%) (CM/EM)	Mean	GAD- 7 scores ≥ 5 (%)	GAD-7 scores 10-14 (%)	GAD-7 score ≥15 (%)	Authors conclusion (differentiate btw. anxiety or symptoms of anxiety)
Baldacci, 2015 ¹¹⁹	Clinical based	200(84)	EM: 84	8.5 ± 5.2"	32	49	16†	Anxiety symptoms
Baldacci, 2015 ¹¹⁹	Clinical based	200(84)	CM:16	8.5 ± 5.2"	32	49	16†	Anxiety symptoms
Lee, 2017 ²²	Clinical based	104(77)	EM:77	5.7 ± 4.0"	N/A	N/A	N/A	Anxiety symptoms
Lee, 2017 ²²	Clinical based	104(77)	CM:23	5.7 ± 4.0"	N/A	N/A	N/A	Anxiety symptoms
Pearl, 2020 ¹²⁰	Clinical based	567(87)	EM:33	5.5 ± 5.2"	48	19	9	Anxiety
Pearl, 2020 ¹²⁰	Clinical based	567(87)	CM:67	5.5 ± 5.2"	48	19	9	Anxiety
Mohseni, 2017 ¹²¹	Clinical based	55(82)	EM:100	N/A	40	47	13	Anxiety
Awaki, 2024 ¹²²	Population-based	17071(67)	100"	5.7 ± 5.5"	27	13	9	Anxiety
Boudreau, 2015 ¹⁰⁷	Clinical based	32(78)	CM:100	8.3 ± 5.7	N/A	N/A	N/A	Anxiety symptoms
Pekdemir, 2022 ¹¹⁵	Clinical based	145(82)	100"	6.0(0-21) ^◊	N/A	N/A	N/A	Anxiety symptoms
Hans, 2023 ¹⁰⁸	Clinical based	111(N/A)	EM:28	6.6 ± 6.0”	N/A	N/A	N/A	Anxiety
Hans, 2023 ¹⁰⁸	Clinical based	111(N/A)	CM: 72	6.6 ± 6.0”	N/A	N/A	N/A	Anxiety
Seo, 2018 ¹⁰⁹	Clinical based	226(84)	EM:44	5.3 ± 5.1”	N/A	N/A	N/A	Not discussed
Seo, 2018 ¹⁰⁹	Clinical based	226(84)	CM: 56	5.3 ± 5.1”	N/A	N/A	N/A	Not discussed
Seng, 2018 ¹¹⁰	Clinical based	90(86)	EM:64	4.1 ± 3.6**	N/A	N/A	N/A	Anxiety
Seng, 2018 ¹¹⁰	Clinical based	90(86)	CM:36	3.7 ± 4.4*	N/A	N/A	N/A	Anxiety
Bond, 2016 ¹⁰⁰	Clinical based	105(100)	CM:16	7.0 ± 5.5	N/A	N/A	N/A	Anxiety symptoms
Bond, 2016 ¹⁰⁰	Clinical based	105(100)	EM:84	7.0 ± 5.5	N/A	N/A	N/A	Anxiety symptoms
Al-Hashel, 2021 (1276	Clinical based	131 (89)	CM:100	12.00 ± 4.40	N/A	N/A	N/A	Anxiety symptoms
Kumar, 2023 ¹¹¹	Clinical based	60(100)	CM:50	6.9 ± 5.9*	N/A	N/A	N/A	Anxiety
Kumar, 2023 ¹¹¹	Clinical based	60(100)	EM:50	8.8 ± 6.0**	N/A	N/A	N/A	Anxiety
Barone, 2024 ¹¹⁴	Clinical based	26(100)	EM:69/CM:31	7.5 ± 7	N/A	N/A	N/A	Anxiety symptoms
Qin, 2022 ¹¹⁶	Clinical based	87(66)	100"	5.0"	N/A	N/A	N/A	Anxiety
Moon, 2017 ¹¹²	Clinical based	227(84)	EM: 55	5.3 ± 5.1"	N/A	N/A	N/A	Anxiety
Moon, 2017 ¹¹²	Clinical based	227(84)	CM:45	5.3 ± 5.1"	N/A	N/A	N/A	Anxiety
Peres, 2019 ¹¹³	Population-based	162(87)	100"	10 ± 5.5”	N/A	N/A	N/A	Anxiety symptoms
Total		19399(74)	EM:40	EM:4.8 ± 5.2	43	38	15
			CM: 36	CM: 9.9 ± 5.5
			“: 24	“: 5.8± 5.5

CM = chronic migraine; EM = episodic migraine; ** = Chronic migraine; * = Episodic migraine ; “= probable migraine/migraine type not specified; N/A = not applicable; ^◊ = median score; †= GAD ≥ 10.

CM = chronic migraine; EM = episodic migraine; “ = migraine type not specified/ probable migraine; N/A = not applicable; ◊ = median score; †= BAI score ≥21.

CM = chronic migraine; EM = episodic migraine; “= Unknown/probable migraine; * = state anxiety; ** = trait anxiety; N/A = not applicable; ◊ = median score; †= STAI-S and STAI-T ≥ 65.

CM = chronic migraine; EM = episodic migraine; PM = probable migraine; “= migraine type not specified; N/A = not applicable.

CM = chronic migraine; EM = episodic migraine; ** = Chronic migraine; * = Episodic migraine ; “= probable migraine/migraine type not specified; N/A = not applicable; ◊ = median score; †= GAD ≥ 10.

Discussion

The main finding of this study is that 42 (41%) out of 98 studies used anxiety screening tools to diagnose anxiety. Among the studies that used the GAD-7, HADS, STAI and BAI, almost half of them used the screening tools as evidence of an anxiety disorder. In comparison, only 29% of studies using HAM-A used the score as an indicator of anxiety.

The use of screening tools as a diagnostic tool for anxiety

In this review, 42 studies were found to use questionnaires as evidence of anxiety. This approach was especially frequent in studies using screening tools validated in patients with migraine such as the GAD-7 and HADS.^17,25 One reason may be that studies have treated screening tools as a diagnostic measure of anxiety.¹²

For example, Spitzer et al. wrote that the GAD-7 scale was designed to reflect the DSM-IV diagnostic criteria for generalized anxiety disorder (GAD),²³ making it a valuable tool to complement clinical assessment and support the DSM-IV criteria for anxiety. However, this may not apply in cases where the screening tools have not been validated. Löwe¹¹⁷ emphasized that a cut-off score ≥10 should be confirmed through extended diagnostic evaluation, highlighting that the screening tool should not stand alone in the diagnostic process. In addition, Veisy et al., concluded that GAD-7 is useful for quick screening, based on their comparison with SCID-5 (Structured Clinical Interview for DSM-5).¹²³ Therefore, the diagnostic interview should still be regarded as essential for both screening and intervention. Of the 98 included studies, only two compared the scores from anxiety screening questionnaires with results from a diagnostic interview for anxiety such as the SCID,^123,124 and only one used the Mini International Neuropsychiatric Interview (MINI) as gold standard to validate its anxiety screening findings.²⁵ Nevertheless in 41% of the included studies, the screening tools were used to conclude that the patients had anxiety. These studies should compare the total screening scores and their subscale scores against a clinical interview to ensure diagnostic accuracy. While this approach is more time-consuming, it is essential for avoiding inaccurate estimates of anxiety prevalence.

Data presentation and interpretation

The presentation of data varied across the included studies, making systematic data collection challenging. In total, sixty studies (63%) reported the proportion of patients with chronic or episodic migraine, while the remaining studies did not distinguish between migraine types.^22,34–3739 –41,44 –46,51 –56,60 –67,69,73 –77,79,80,82 –84,87,88,90,92,94,96,98,100,104 –109,111,112,114,118 –122,125,126 Eighty-three studies reported the mean screening score, and eight reported the median score. Different cut-off points were used in the studies, although most followed the standard cut-off points.^1–4148,64,89,101,118 This may compromise cross-study comparisons and reduce the validity of the studies. Not all studies that concluded the presence of anxiety based on screening scores explicitly stated that the patients had anxiety. Instead, they emphasized that the score was an indicator of symptoms of anxiety. Phrases like “the percentage of patients meeting the criteria for anxiety and depression, was”⁴⁰ and “the higher the score, the worse symptoms of anxiety”^74,86 were used. Such phrasing can be unclear and potentially misleading, as it may lead readers to assume that a clinical diagnosis had been made. While symptom scores may indicate the presence of anxiety symptoms, they do not necessarily equate to a clinical diagnosis. Accordingly, some authors who had screened for anxiety using a screening tool acknowledged that this method cannot replace diagnoses based on ICD or DSM criteria.^8,36,115 The heterogeneity in data presentation, inconsistent cut-off points, and lack of clarity in reporting illustrate the methodological challenges across studies. These issues complicate cross-study comparison and highlight the need for clearer definitions and more precise data reporting in future migraine studies.

Selecting the appropriate screening tool

Selecting the appropriate screening instrument is essential, as its psychometric characteristics affect the accuracy of results.¹²⁷ If a screening tool has not been validated in the migraine patient population, its interpretability and usefulness are substantially reduced. Not accounting for these variables may result in misleading estimates of the prevalence of anxiety in patients with migraine.

Stein et al. argued that the GAD-7 is not specific to generalized anxiety disorder but is also relatively sensitive to other anxiety disorders.¹²⁸ In the context of migraine research, a high GAD-7 score can therefore reflect generalized anxiety, but it could also indicate other anxiety-related disorders. This supports the idea that screening tools are limited; they can measure the presence of anxiety symptoms but cannot differentiate between distinct anxiety disorders. Therefore, identifying overlapping conditions can help refine screening instruments, enabling them to distinguish true psychiatric disorders from comorbid symptoms. Even when an anxiety screening tool has been validated in the general population, its reliability must be critically reassessed in headache patients. An additional methodological issue rarely reported is whether anxiety screening questionnaires were completed during a migraine attack or outside of the migraine attack period. Since migraine related somatic symptoms can overlap with symptoms of anxiety, completing questionnaires during an attack may influence the reported anxiety scores. Future studies should therefore report whether questionnaires were completed in relation to migraine symptoms.

For instance, in a study involving 50 women, researchers compared the SCID with the Patient Health Questionnaire (PHQ) and found that the PHQ failed to identify 44% of the patients who met SCID criteria for at least one anxiety disorder.¹²⁹ Moreover, inconsistencies across studies have been reported regarding recommended cut-off scores, as well as the sensitivity and specificity of various screening tools.^17,127 These inconsistencies can have both clinical and economic consequences. For example, in a systematic review¹³⁰ evaluating the accuracy of HADS in cancer patients, the authors reported variation in the threshold/cut-offs generated in varying prevalence estimates of both anxiety and depression. Consequently, selecting a screening instrument requires careful evaluation of its cut-off scores, validity, reliability and inherent limitations. Addressing these factors can improve the accuracy and interpretability of the screening results.

The study population

In this review, 93% of the studies were clinical-based. These patients are likely to have more complex medical histories than those in the general migraine population, which may contribute to a higher prevalence of anxiety. Studies comparing patients with headaches to healthy controls have shown that those attending a headache clinic experience a greater disease burden. They score higher on psychological scales and report more intense “most severe headache”.¹³¹ Together, these observations highlight the need for more population-based studies to investigate the prevalence of anxiety in migraine. Comparisons between patients with chronic migraine and episodic migraine have demonstrated that higher headache frequency and intensity are associated with a greater disease burden and disability as well as anxiety.^2,132 To better understand the prevalence of anxiety across different patient groups, it is thus essential to divide patients by headache frequency or intensity.^133,134 Despite the use of similar anxiety screening tools, results varied considerably. This likely reflects the differences in the proportion of patients with chronic and episodic migraine and whether studies differentiated between these subgroups. Studies with a greater number of chronic patients with migraine tended to report higher mean scores and more patients in the moderate-to-severe range. In studies that did not categorize patients into subgroups, it is difficult to identify which factors may have influenced the results. Some studies may have divided patients by the occurrence of aura which we did not consider in this review. Over 80% of the participants in the included studies were female. Women generally report a higher migraine disease burden compared with men,^132,135 and generally report higher anxiety scores. Therefore, the proportion of female participants should also be considered when interpreting study findings.

Comparing anxiety and depression screening tools in migraine

Depression-migraine comorbidity has been investigated, and studies have reported that migraine sufferers are two to four times more likely to experience depression. Asheer et al. found 35 out of 78 included studies (45%) of migraine-depression studies used screening tools as evidence of depression, equating a score above a cut-off with a diagnosis.¹³⁶ This approach tends to inflate prevalence estimates compared to diagnostic interviews; a finding supported by this study as well. Furthermore, Asheer et al. noted that only a few screening tools are formally validated for patients with migraine with only PHQ-9 and HADS-D validated in a headache population. Gantenbein et al. also emphasizes that the lack of migraine-specific validation is problematic since overlapping symptoms between migraine and depression can distort screening results.¹³⁷ As mentioned earlier, comparing the questionnaire results to structured psychiatric interviews provided the most accurate estimate of a diagnosis. In this review, very few studies made this comparison. Likewise, Asheer et al. found one out of 78 included studies used this method. As a result, the true accuracy of many anxiety screening tools in a migraine population remains uncertain. When comparing the use of anxiety screening tools versus depression screening tools in migraine, depression has received more methodological attention. For example, Levis et al. found that depression prevalence in migraine was 31% when using screening questionnaires but dropped to 17% with formal diagnostic criteria.¹³⁸ In contrast, anxiety screening tools have not undergone the same level of methodological scrutiny as depression. One study investigated the benefits and harms of an anxiety screening program and found evidence was insufficient to draw definitive conclusions.¹³⁹ Thus, anxiety screening tools have been evaluated to some extent, but the volume and depth of research remain more limited than for depression.

Limitations

This review has several limitations. As this study was designed as a narrative review rather than a formal systematic review, the literature search was limited to a single database (PubMed), and all studies were screened by one author (M.Y.H.P.). This may have increased the likelihood of unintentional exclusion of relevant studies, which could affect the quality and reliability of the review. This approach may also have increased the risk of selection bias during the screening process. Furthermore, not all retrieved studies were available in full text, leading to their exclusion. Additionally, several studies did not report mean scores or the percentage of participants within each severity level. Thus, reducing the amount of data. Moreover, not all included studies reported the proportion of patients with medication overuse, meaning some patients with medication-overuse headache (MOH) may have been included despite the exclusion criteria. One study found that anxiety and depression were more common in patients with MOH compared with patients with episodic migraine.¹⁴⁰ This may have caused patients with MOH to score higher on anxiety screening tools, contributing to variations across studies. In addition, no protocol was published or registered before the review was conducted, which limits methodological transparency and makes it more difficult to assess whether the review methods were prespecified. Given these methodological challenges, alternative approaches to improving the diagnostic validity have been proposed. One study suggested that headache studies investigating comorbid depression should apply the LEAD (Longitudinal Expert Assessment of All Data) as an index of validity.¹⁴¹ There is reason to believe that the same approach can be applied to anxiety in headache studies. Like depression, anxiety is characterized by variable symptoms and frequent somatic comorbidities which can make the LEAD a useful tool for improving diagnostic accuracy.¹⁴²

Conclusion

Among the 98 studies that used anxiety screening tools in patients with migraine 42 (41%) of the studies applied the screening tools as evidence of anxiety. However, the screening tools are not intended to replace a validated diagnostic interview conducted by a psychiatrist for diagnosing anxiety disorders. Instead, they should only be used to measure the presence and severity of anxiety symptoms. A further challenge is the limited validation of these screening tools, as a few studies have compared them with a psychiatric gold standard such as structured diagnostic interviews (SCID and MINI) in patients with migraine. This process is further complicated by the overlap between anxiety symptoms and migraine-related somatic features which makes accurate assessment more difficult. This makes it harder to evaluate the accuracy of these tools. Therefore, studies should prioritize using screening tools that have been validated for the specific population under study, and authors should critically evaluate the obtained scores. Moreover, further research is needed to validate commonly used anxiety screening tools in patients with migraine such as HADS-A, HAM-A, GAD-7, and BAI. Overall, there is a need for clear guidelines regarding the use of anxiety screening instruments in patients with migraine. These implications of this review should, however, be interpreted with caution given the narrative design of the review, the use of a single database, the single reviewer screening process, and the absence of a published protocol.

Public health relevance

Almost half of the eligible studies used anxiety screening tools as evidence of anxiety, whereas only a few studies confirmed the diagnosis with a structured diagnostic interview. This resulted in potentially erroneous estimates of the prevalence of anxiety among patients with migraine.

Correct diagnosis of anxiety disorders should be conducted in accordance with national and international guidelines and should not rely on a single screening questionnaire.

More studies are needed to further validate commonly used anxiety screening tools in patients with migraine, such as the HADS A, GAD 7, HAM A, BAI and STAI.

Clear guidelines for the use and interpretation of anxiety screening tools in patients with migraine are needed.

Footnotes

Acknowledgements

None.

ORCID iDs

Jasmin Asheer

Henrik Winther Schytz

Ethical considerations

The manuscript is a narrative review not requiring ethical reporting.

Consent to participate

Not applicable.

Consent for publication

All authors have reviewed and approved the final version of the manuscript and agree to publication in Cephalalgia, if accepted.

Author contributions

M.Y.H.P.: Conceptualization, Methodology, Investigation, Data Curation, Writing – Original Draft.

J.A.: Conceptualization, Writing – Review & Editing.

F.A.: Conceptualization, Writing – Review & Editing.

R.H.: Conceptualization, Writing – Review & Editing.

P.V.: Conceptualization, Writing – Review & Editing.

H.W.S.: Conceptualization, Methodology, Project Administration, Supervision, Writing – Review & Editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

Data availability is not applicable, as this is a narrative review based on previously published studies.

Open practices

Not applicable.

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