Association of Anxiety and Depressive Symptoms, Disorders, and Migraine in Pediatric Patients

In this video, Serena Orr, MD, MSc, speaks about her team’s study, “Anxiety and Depressive Symptoms and Disorders in Children and Adolescents With Migraine.” Dr Orr talks about how the results of the study may impact clinical care, the ideal approach to treating a pediatric patient with migraine and symptoms of anxiety, and what are the current gaps in research on this topic.

Additional Resource: 

• Falla K, Kuziek J, Mahnaz SR, Noel M, Ronksley PE, Orr SL. Anxiety and depressive symptoms and disorders in children and adolescents with migraine. JAMA Pediatr. 2022;176(12):1176-1187. doi:10.1001/jamapediatrics.2022.3940

For more migraine content, visit the resource center.

Serena Orr, MD MSc, is a pediatric neurologist and headache specialist at the Alberta Children's Hospital, and an assistant professor at the Cumming School of Medicine, Department of Pediatrics at the University of Calgary (Calgary, Alberta, Canada).

TRANSCRIPTION: 

Serena Orr, MD, MSc: Hello, I'm Dr. Serena Orr. I'm a pediatric neurologist and a headache specialist at the Alberta Children's Hospital in Calgary, Alberta, in Canada. I'm a clinician scientist and my research interest is in better understanding migraine in children and adolescents, both the relationship between migraine and mental health, and advancing treatment for children and adolescents with migraine.

How do your findings contribute to to the existing literature on the association of anxiety and depressive symptoms, disorders and migraine in pediatric patients?

Dr Orr: Basically the premise of this study is that there have been quite a few studies over the last few decades that have tried to tease apart whether there's a relationship between anxiety, depression and migraine, in youth. And what we wanted to do is really try to put all of these studies together to see if we could find a consistent message out of them. So what we did is called a systematic review. We pulled all of the studies that met our criteria together that were looking at the question of do children and adolescents who have migraine have more anxiety and depressive symptoms, as well as disorders, compared to peers without migraine?

And so that's basically what we did, is we did a systematic search. We found almost 5,000 studies, then we paired them down in two stages, down to 80 studies that were meeting our criteria for inclusion. And we were able to then look at that data, both qualitatively and quantitatively, to look at our question. So yeah, our main objective was to look at the association, but then we also had a couple of other objectives. So not only anxiety and depression, are they associated with migraine in youth, but does having anxiety or depression predict different outcomes in youth with migraine? And also does having anxiety or depression earlier in life, is that associated with developing migraine later in childhood or adolescents? So those were the three questions that we looked at in our study.

How do your results impact clinical practice?

Dr Orr: Yeah, so what we did when we paired all of this information down is we found... We did a meta-analysis, so we did a quantitative analysis of our first question about whether there's an association between anxiety and depressive symptoms, and disorders, and migraine, in children and adolescents. And we found that there was, for all of those things. So children and adolescents with migraine had a moderate to large association between anxiety symptoms and migraine, and also about a doubling of the odds of having anxiety disorder compared to healthy controls. And then similarly for depressive symptoms, we found a strong association, and a doubling of the odds of depressive disorders among children and adolescents with migraine compared to peers.

And so this I think is really important information because before this, there were all of these studies out there, nobody was able to pull them together, and there was still a debate in the field as to whether children and adolescents with migraine are at higher risk of having internalizing symptoms or disorders. And I think now this really does tell us. Yeah, we put it all together. There's pretty strong associations here. This is a real thing that we need to pay attention to in clinical practice. So I think really our results underscore the need to screen for mental health symptoms, particularly anxiety and depression, in any child or adolescent presenting with migraine.

And then to do something about it. We don't know though, because there were very few studies that actually looked at our second and third question. So those are the questions on, okay, well we have this association, but does that mean that there's different outcomes in a child or adolescent who has migraine and anxiety and or depression, or do... We don't also know whether having anxiety or depressive symptoms earlier in life is associated with development of migraine. So we don't know those things yet. And I think it's important that yes, we screen for them, we manage the symptoms if they're there, but to not make assumptions that, for example, this child is not getting better from a headache perspective because they're depressed, because we don't know that and it's very unclear, and there's not a lot of studies that have looked at those specific questions.

Looking ahead, what are the gaps in our knowledge that future studies could potentially investigate?

Dr Orr: Good question. It does lead into what I was discussing. And so there's a few things that we definitely don't know. So we know that there's this association, but we don't know what's chicken or egg, or even if there's any causative relationship between the two. So future studies, I think I'm really interested to see, do children and adolescents who have higher anxiety or depressive symptoms at baseline, is that associated with a different migraine disease course? We don't know that. A lot of people assume that that's the case, but we don't know because there's too few studies. So I think we need adequately powered, well-designed cohort studies that follow children and adolescents with migraine over time, measure their mental health symptoms, and try to understand if there's any relationship between the mental health and the pain-related symptoms.

Most of the studies, so we found about nine studies or so if I recall that looked at that question in our systematic review, but most of them were in small samples, they were clinical samples. I think we need big population-based studies so that we can capture a more representative sample of children and adolescents with migraine, and answer the question in a more robust way. We don't know either, because there were only two studies that looked at this question as to whether having anxiety or depression earlier in life, or flipping that on its head, having migraine earlier in life is associated with, in the case of mental health to migraine, is there an association there with having mental health symptoms earlier in life, is that associated with developing migraine later? Or vice versa, is having migraine earlier in life associated with mental health symptoms down the road? So these are still questions that haven't been answered or looked at in enough studies for us to know. And I think they're interesting, because they may help us understand migraine disease better.

And then, we know there's this association, why is it there? Again is it chicken or egg? Or maybe is this a genetic association, that genetically migraine and depression, for example, travel together? There's a little bit of data on that in adult samples. Or does having mental health symptoms like anxiety or depression earlier in life during critical periods, does that skew the brain towards a developmental pathway that's more prone to pain? These are all things I think that really could be looked at in the future and can help us understand the disease better.

Which specialists would be interested in the results of your study, and why?

Dr Orr: I think any person who's managing a child or an adolescent with a headache disorder, particularly migraine, would be interested. And given that the data suggests that it's about one in 10 children and adolescents who will have migraine at some point before adulthood, that could be anyone from primary care, to pediatricians, to pediatric neurologists, emergency physicians. I think this is really broadly relevant because this is a very common, burdensome disease that many, many practitioners are going to see and have to manage. And I think if we're going to do justice to managing migraine in this population, we should screen for these mental health symptoms because they're so common.

Is a multidisciplinary approach to treatment for young patients with migraine who show symptoms of anxiety and depressive disorders a realistic management option?

Dr Orr: I think there's what's ideal and what's realistic in certain practice settings. I do think that this... Hopefully this data will really spur a conversation about the importance of multidisciplinary care, because most practitioners who are seeing patients in a general practice or even a neurology practice, may not have the time, training or resources to adequately manage the mental health symptoms. And I don't want to overgeneralize too much, because there's a lot of, for example, wonderful pediatricians that I work with in the community who are great at managing both. But I think in the ideal world, you would have a multimodal treatment approach that somebody is managing the headache symptoms in tandem with a mental health provider if they do screen positive for anxiety or depression.

We also know, and this is a bit of a side answer I suppose, that for children and adolescents with chronic migraine, there's really high level data that cognitive behavioral therapy for pain is very effective in reducing headache frequency. Cognitive behavioral therapy for pain may not directly address anxiety or depression, or may address, encompass it in the approach, but it still is a psychological approach that we know there's a lot of data for. And it's typically delivered by a mental health provider as opposed to a physician or a nurse practitioner. So in the ideal universe, we would have multidisciplinary care, but I also think skilled primary care providers and pediatricians can do a really good job at managing both the pain and the mental health symptoms together.

What are the overall take home messages from our conversation today?

Dr Orr: So I'd like to just emphasize that I think this is high level data to support the clinical recommendation to screen for anxiety and depressive symptoms in children and adolescents with migraine. But I also want to take home the message that we don't yet really understand that relationship very well in a replicated manner. And we don't understand what's chicken or egg. We don't know if mental health impacts outcomes. We don't know if the mental health symptoms leads to development of migraine, or vice versa, or neither. And so although we know there's an association, there's still many unanswered questions, and we shouldn't bias our clinical practice by assuming the answers to some of those questions. But definitely engage in screening and try to establish appropriate referral sources for patients who are experiencing both migraine and anxiety or depressive symptoms.

I want to thank everybody for their attention today. I think this is a really important topic. Like I said, one in 10 children and adolescents have migraine, and we really have to have more pediatric specific studies to better understand this really prevalent and burdensome disease in the pediatric population. So thanks for listening today.