Aalborg Universitet
Anxiety, Depression, and Body Weight in Children and Adolescents With Migraine
Tarantino, Samuela; Papetti, Laura; Di Stefano, Alessandra; Messina, Valeria; Ursitti,
Fabiana; Ferilli, Michela Ada Noris; Sforza, Giorgia; Moavero, Romina; Vigevano, Federico;
Gentile, Simonetta; Valeriani, Massimiliano
Published in:
Frontiers in Psychology
DOI (link to publication from Publisher):
10.3389/fpsyg.2020.530911
Creative Commons License
CC BY 4.0
Publication date:
2020
Document Version
Publisher's PDF, also known as Version of record
Link to publication from Aalborg University
Citation for published version (APA):
Tarantino, S., Papetti, L., Di Stefano, A., Messina, V., Ursitti, F., Ferilli, M. A. N., Sforza, G., Moavero, R.,
Vigevano, F., Gentile, S., & Valeriani, M. (2020). Anxiety, Depression, and Body Weight in Children and
Adolescents With Migraine. Frontiers in Psychology, 11, [530911]. https://doi.org/10.3389/fpsyg.2020.530911
General rights
Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners
and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.
? Users may download and print one copy of any publication from the public portal for the purpose of private study or research.
? You may not further distribute the material or use it for any profit-making activity or commercial gain
? You may freely distribute the URL identifying the publication in the public portal ?
Take down policy
If you believe that this document breaches copyright please contact us at vbn@aub.aau.dk providing details, and we will remove access to
the work immediately and investigate your claim.
ORIGINAL RESEARCH
published: 28 October 2020
doi: 10.3389/fpsyg.2020.530911
Anxiety, Depression, and Body
Weight in Children and Adolescents
With Migraine
Samuela Tarantino 1*, Laura Papetti 2, Alessandra Di Stefano 1, Valeria Messina 1,
Fabiana Ursitti 2, Michela Ada Noris Ferilli 2, Giorgia Sforza 2,3, Romina Moavero 2,3,
Federico Vigevano 2, Simonetta Gentile 1 and Massimiliano Valeriani 2,4
1
Unit of Clinical Psychology, Department of Neuroscience and Neurorehabilitation, Ospedale Pediatrico Bambino Gesù, Istituto
di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy, 2Headache Center, Division of Neurology, Ospedale Pediatrico
Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy, 3Child Neurology and Psychiatry Unit,
Tor Vergata University of Rome, Rome, Italy, 4Center for Sensory-Motor Interaction, Aalborg University, Aalborg, Denmark
Edited by:
Roberto Truzoli,
University of Milan, Italy
Reviewed by:
Emanuele Preti,
University of Milano-Bicocca, Italy
Guido Giovanardi,
Sapienza University of Rome, Italy
Tommaso Boldrini,
University of Padua, Italy
*Correspondence:
Samuela Tarantino
samuela.tarantino@gmail.com
Specialty section:
This article was submitted to
Psychology for Clinical Settings,
a section of the journal
Frontiers in Psychology
Received: 30 January 2020
Accepted: 28 September 2020
Published: 28 October 2020
Citation:
Tarantino S, Papetti L, Di Stefano A,
Messina V, Ursitti F, Ferilli MAN,
Sforza G, Moavero R, Vigevano F,
Gentile S and Valeriani M (2020)
Anxiety, Depression, and Body
Weight in Children and Adolescents
With Migraine.
Front. Psychol. 11:530911.
doi: 10.3389/fpsyg.2020.530911
Frontiers in Psychology | www.frontiersin.org
Background: There is a lack of studies that explore the possible association between
body weight, psychological symptoms, and migraine severity in pediatric populations.
The purpose of the study was to explore: (1) the association between body weight and
the frequency of migraine attacks, (2) the possible differences in anxiety and depression
symptoms according to the frequency of attacks and body weight, and (3) the possible
mediating role of anxiety and/or depression in the association between body weight and
frequency of migraine attacks in children.
Methods: One hundred and eleven children/adolescents with migraine were included
(47 boys and 64 girls; mean age 11.7; ±2.4 years). The patients were classified as: (1)
high frequency patients, reporting from weekly to daily episodes and (2) low frequency
patients, with ≤3 episodes per month. According to their body mass index percentiles,
the patients were divided in “Normal weight” (from ≥5 to <85 percentile), “Overweight”
(from ≥85 to <95 percentile), and “Obese” (≥95 percentile). Given the low number of
obese patients, the overweight and obese groups were considered together in the
“Overweight” group. Anxiety and depression symptoms were assessed by the SelfAdministered Psychiatric Scales for Children and Adolescents (SAFA).
Results: Fifty-four patients were normal in weight (49.6%), while 56 patients (50.4%)
were overweight. The overweight patients showed a higher frequency of migraine attacks
(64.7%; p < 0.05). Patients with a high frequency of attacks reported higher scores in all
SAFA-Anxiety subscales (SAFA-A Tot: F = 15.107; p = 0.000). Overweight patients showed
a significantly higher score in the “Separation anxiety” subscale (F = 7.855; p = 0.006).
We found a mediating role between the overweight and high frequency for total anxiety
(z = 2.11 ± 0.03; p < 0.05) and social anxiety (z = 2.04 ± 0.03; p < 0.05).
Conclusions: Our results suggest that, among the children suffering from migraine, the
overweight status is associated with a higher frequency of attacks and separation anxiety
symptoms. In particular, our study provides the first evidence of the role of anxiety in
linking overweight and the frequency of migraine attacks in children and adolescents.
Keywords: children, migraine frequency, body weight, anxiety, depression
1
October 2020 | Volume 11 | Article 530911
Tarantino et al.
Pediatric Migraine, Weight, Emotional Factors
INTRODUCTION
both the central and peripheral pathophysiological mechanisms
(Chai et al., 2014b; Oakley et al., 2014; Ravid, 2014; Farello
et al., 2017). There is also an emerging evidence that some
psychological factors, such as anxiety, depression, and stress,
may influence this relationship (Ravid, 2014; Ornello et al.,
2015). The association between headache and psychological
symptoms has been widely documented. In particular, symptoms
of anxiety and depression are very common among patients
suffering from chronic migraine, both in adult (Antonaci et al.,
2011; Kyungmi et al., 2014) and pediatric ages (Powers et al., 2006;
Antonaci et al., 2011; Dindo et al., 2017).
Three main potential mechanisms have been hypothesized
to explain this connection: (1) Stressful life events, anxiety,
and depression may influence the onset, maintenance, and
exacerbation of migraine (Merikangas et al., 1990; Radat and
Swendsen, 2005; Antonaci et al., 2011); (2) pain itself may
be a vulnerability factor leading to increased psychosocial
problems, increased stress, anxiety, and depression (Merikangas
et al., 1990; Radat and Swendsen, 2005; Antonaci et al., 2011);
and (3) common determinants (e.g., neurotransmitters or
receptors; Antonaci et al., 2011) and environmental, contextual,
and interpersonal vulnerability factors can contribute to this
association (Tarantino et al., 2017, 2018).
Little is known about the psychological profile of headache
patients who suffer from being overweight. Data concerning
the possible association between body weight, psychological
factors, and headache are sparse, and involves only adult patients
(Tietjen et al., 2007; Bond et al., 2015; Galioto et al., 2017).
In adulthood, a significant interaction was found between some
psychological symptoms, such as depression/anxiety, coping style,
stress, migraine frequency, and overweight (Tietjen et al., 2007;
Bond et al., 2015; Galioto et al., 2017).
Migraine and obesity are very common problems in the pediatric
age (Verrotti et al., 2012; Oakley et al., 2014; Farello et al.,
2017). Previous epidemiological studies showed a prevalence
of migraine ranging from 3% in preschool age to 8–23% during
adolescence (Bellini et al., 2013; Genizi et al., 2016). Similarly,
the pediatric overweight and obesity are more prevalent over
the last decades (Verrotti et al., 2012; Farello et al., 2017).
Both conditions are multifactorial diseases, influenced by genetic,
environmental, and psychological factors (Strauss, 2000; Lipton
and Bigal, 2005; Friedman and De ver Dye, 2009; Albuquerque
et al., 2017; Marmura, 2018), are associated with a poor quality
of life, high healthcare costs, and increased risk of psychological
disorders (Abu Bakar et al., 2016; Apovian, 2016; Öztop et al.,
2016). In particular, patients suffering from high frequency of
migraine attacks are more likely to report a more negative
life impact due to pain (Malone et al., 2015).
In recent years, a growing body of literature analyzed the
association between obesity and migraine, both in adult (Bigal
et al., 2006; Bigal and Lipton, 2006; Winter et al., 2012; Chai
et al., 2014a,b; Ornello et al., 2015; Togha et al., 2019) and
pediatric ages (Verrotti et al., 2012; Oakley et al., 2014; Ravid,
2014; Eidlitz-Markus et al., 2015; Farello et al., 2017). Many
studies supported the role of being overweight on headache
severity and, in particular, in the transformation of migraine
from episodic to chronic (Bigal et al., 2006; Bigal and Lipton,
2006; Winter et al., 2012; Ornello et al., 2015). Moreover,
there is evidence of a beneficial effect of weight loss on headache
severity (Bond et al., 2011; Novack et al., 2011). In spite of
these findings, literature data are far from being conclusive
(Pakalnis and Kring, 2012; Ornello et al., 2015; Farello et al.,
2017). Some authors did not confirm the association between
overweight and migraine (Gilmore, 1999; Le et al., 2011; Pakalnis
and Kring, 2012; Eidlitz-Markus et al., 2015). The disagreement
may be due to the heterogeneity in the methodological designs
and inclusion criteria of the patients. In adulthood, age and
gender are considered as factors that may influence the
relationship between weight and migraine (Ornello et al., 2015).
A possible role of hormonal status in contributing to the
migraine/body weight association has been proposed in women
(Peterlin et al., 2010, 2013; Ornello et al., 2015). So far, only
a few studies exploring the association between body weight
and migraine severity in children and adolescents have been
conducted (Pinhas-Hamiel et al., 2008; Kinik et al., 2010;
Pakalnis and Kring, 2012; Ravid et al., 2013; Eidlitz-Markus
et al., 2015). Moreover, some of them did not include the
patients who referred to a specific pediatric headache center
(Pinhas-Hamiel et al., 2008; Kinik et al., 2010; Ravid et al., 2013;
Eidlitz-Markus et al., 2015).
Several elements support the hypothesis that the association
between migraine and overweight may be multifactorial, involving
Purpose of the Present Study
Our study aimed at exploring the role of weight and
psychological symptoms on migraine severity. In particular,
we investigated: (1) the association between body weight and
the frequency of migraine attacks, (2) the possible differences
in anxiety and depression symptoms according to the frequency
of attacks and body weight, and (3) the possible mediating
role of anxiety and/or depression in the association between
body weight and frequency of migraine attacks in children.
We hypothesized that: (1) Overweight children would report
a higher severity of pediatric migraine (i.e., frequency of
attacks) compared to the normal weight ones; (2) anxiety
and depression symptoms would be higher in children/
adolescents complaining with a high frequency of attacks
and in those who are overweight; and (3) anxiety and/or
depression could mediate the relationship between being
overweight and high frequency of headache.
MATERIALS AND METHODS
Abbreviations: ICHD-III, Headache Classification Committee of the International
Headache Society; HF, High frequency; LF, Low frequency; NW, Normal weight;
OW, Overweight; SAFA, Psychiatric scales for self-administration for youths and
adolescents; SAFA-A, SAFA-anxiety; SAFA-D, SAFA-depression.
Frontiers in Psychology | www.frontiersin.org
Participants
This study was conducted prospectively from January 2015 to
April 2017. Participants were recruited among children/adolescents
2
October 2020 | Volume 11 | Article 530911
Tarantino et al.
Pediatric Migraine, Weight, Emotional Factors
who were referred for consultation to the Headache Center,
Division of Neurology, of Bambino Gesù Children’s Hospital in
Rome. One hundred twenty-four children/adolescents suffering
from migraine without aura were involved. One hundred eleven
of these were included in the study (47 boys and 64 girls; age
range 8–18 years; mean age 11.7 ± 2.4 years). At the first visit,
every patient underwent a neurological examination and a general
physical exam including weight and height determination.
Headache diagnosis was made according to the criteria of the
International Classification of Headache Disorders, 3rd edition
[ICHD-III; Headache Classification Committee of the International
Headache Society (IHS), 2013]. We excluded from our study
the following: (1) patients with the presence of any internal
conditions or other neurological diseases (four participants); (2)
children/adolescents who were taking drugs for migraine
prophylaxis and other medications acting on the central nervous
system (one patient); and (3) underweight patients (eight patients).
Children/adolescents who had previously received medications
for acute attacks of pain (i.e., triptans, ibuprofen, and paracetamol)
were not excluded from the study.
in our study (Cianchetti and Sannio Fascello, 2001). The
battery of tests was structured in six scales, which can be used
either together or separately; each scale is divided into several
subscales. The SAFA assessment explores a wide series of
psychiatric symptoms and psychological conditions: anxietyrelated areas (SAFA-A), depression-related areas (SAFA-D),
somatic concerns (SAFA-S), obsessive-compulsive symptoms
(SAFA-O), psychogenic eating disorders (SAFA-P), and phobias
(SAFA-F).
It leads to an individual profile (including one of the
above-mentioned scales and the related subscales) and to a
global profile. The entire battery of tests can be completed
in 30–60 min.
In relation to age, the questionnaire was organized in two
versions: “e” for patients aged 8–10 years and “m/s” for those
aged 11–18 years. SAFA-A was divided in three forms: “e”
for 8–10 years, “m” for 11–13 years, and “s” for 14–18 years.
For each item, the subject has three possible answers: “true
(scoring 2), partly true (scoring 1), and false (scoring 0).”
The sum of points obtained in each scale and subscale can
be converted into T scores, sten, points, and percentiles.
SAFA-A includes four subscales producing a “Total anxiety”
score: “Generalized anxiety,” “Social anxiety,” “Separation anxiety,”
and “School anxiety.” The questionnaire is composed of 42
items for the “e” version and 50 items for the “m/s.”
Also SAFA-D leads to a total score and includes seven
subscales: “Depressed mood,” “Anhedony/disinterest,” “Toucy
mood,” “Sense of inadequacy/low self-esteem,” “Insecurity,”
“Feeling of guilt,” and “Hopelessness.” The scale consists of 48
items for the “e” version and 56 for the “m/s” version.
Within these scales, there are “items of lies,” six for SAFA-D
“e,” and the same six plus one for SAFA-D “m-s,” in order
to verify the reliability of the answers (Cianchetti and
Sannio Fascello, 2001).
The SAFA battery was validated. It showed good psychometric
properties (Cianchetti and Sannio Fascello, 2001; Franzoni
et al., 2009; Pellicciari et al., 2012). In our study, the Cronbach’s
test showed α values of 0.84 for answers to SAFA anxiety
questions and of 0.77 for SAFA depression. Also, considering
the SAFA Anxiety and Depression together, the α value was
reliable (α = 0.81).
The same examiner (ST, with a specific training in
psychological assessment in pediatric age) administered the
psychological screening tests in a single session. The evaluation
consisted of a psychological interview and the administration
of the SAFA-A and SAFA-D questionnaires performed in the
second visit. To avoid a possible effect of pain on the psychological
evaluation, we made sure that all patients were free from
headache 24 h before the psychological screening. Moreover,
all patients had to be able to read, understand, and answer
every item of the questionnaires.
Measures
Frequency of Migraine Attacks
Data on the course of migraine were issued from a headache
diary given at the first consultation and brought back by the
family at the second consultation. According to the aim of
our study, we extrapolated only the frequency of the attacks.
Patients were classified into two groups: (1) high frequency
(HF; participants complaining from weekly to daily attacks)
and (2) low frequency (LF; children/adolescents with ≤3 episodes
per month). The aforesaid break point was chosen for three
main reasons: (1) Children/adolescents suffering from
intermediate and chronic frequency of attacks were too few
to allow a reliable statistical analysis; (2) a mere distinction
between episodic and chronic migraine would have led to
pool patients with a high but not chronic frequency of attacks
with patients with a very low frequency of attacks; and (3)
patients in need of preventive treatment were separated from
patients without such requirement (Tarantino et al., 2014).
Body Mass Index
The patients’ weight status was evaluated according to the body
mass index (BMI), calculated as the body mass divided by
the square of the body height. BMI was calculated taking into
account the sex and age. According to BMI value, the patients
of each group were classified as: (1) underweight (under 5th
percentile), (2) normal weight (NW; from 5th to 85th), (3)
overweight (from 85th to 95th), and (4) obese (over 95th;
Cacciari et al., 2006). To overcome the unbalanced distribution
of this variable in our sample (low number of obese subjects),
the overweight and obese groups were merged together (OW;
“overweight”).
Statistical Analysis
Statistical analysis was performed using the SPSS 22.0 software
(Statistical Package for the Social Sciences). According to the
aim of our study, the patients were grouped according to the
frequency of attacks and weight.
Anxiety and Depressive Symptoms
The Italian Self Administrated Psychiatric Scales for Children
and Adolescents battery of tests was the assessment tool used
Frontiers in Psychology | www.frontiersin.org
3
October 2020 | Volume 11 | Article 530911
Tarantino et al.
Pediatric Migraine, Weight, Emotional Factors
vs. 11.6 ± 2.1 years, χ2 = 0.44; respectively; p > 0.05), and
between the NW and OW patients (11.6 ± 2.3 years vs.
11.1 ± 2.4 years, respectively; χ2 = 0.51; p > 0.05).
Chi square test was used to verify the differences between
NW and OW patients in terms of the frequency of attacks
(high or low). The univariate logistic regression was used to
estimate the risk of high-frequency of attacks associated
with BMI.
The ANOVA test was used to compare the SAFA scores
between the patients with low and high frequency of attack,
and between NW and OW patients.
Statistical significance was determined using the two-tailed
test and value of p was fixed at p < 0.05. A post-hoc correction
for multiple comparisons was made using the Bonferroni’s test,
setting the significance cut-off at a/n with a = 0.05 and final
value of p = 0.025.
To verify the possible mediating effect of the anxiety and
depressive symptoms on the frequency of the attacks, we carried
out a mediation analysis using the Sobel’s test (z-value). In
particular, the SAFA scores that proved significant in the
ANOVA test were considered as possible mediators.
Difference in Anxiety and Depression
Symptoms Between Children With High
and Low Frequency of Migraine Attacks
High frequency children showed higher levels of total anxiety
as compared with the LF patients (SAFA-A Tot: F = 15.107;
p < 0.0001 (Table 2). In particular, with regard to the differences
in the SAFA-Anxiety and Depression subscales between the
groups, we found that the HF patients reported higher scores
in all the SAFA-A subscales (p < 0.025), suggesting that the
HF patients were more anxious in several fields, such as school
(p < 0.025), social relationships (p < 0.025), and separation
from parents (p < 0.025; Table 2). Although the HF patients
showed a higher mean score in the SAFA-D Total scale, we did
not find a significant difference between the two groups (SAFA-D
Tot: F = 4.270; p < 0.025). No difference in the SAFA-D
subscales was found between the HF and LF patients (p > 0.025;
Table 2).
RESULTS
Sample Characteristics
Difference in Symptoms of Anxiety and
Depression Between Overweight and
Normal Weight Children
Fifty-five patients were normal weight (49.6%), while 56 patients
(50.4%) were classified as overweight (overweight/obese).
Overweight/obese patients had a mean BMI of 29.5 ± 5.2.
Most children had a low frequency of attacks (60; 54.0%),
whereas 51 patients (45.9%) reported a high frequency.
Comparing the SAFA-Anxiety and Depression between the
NW and OW patients, a significant difference between the
groups was found. In particular, the OW patients showed
significantly higher scores in the “Separation anxiety” subscale
(F = 7.855; p < 0.01). No other differences between the groups
were found in the SAFA-A subscales (SAFA-A Tot: F = 1.849;
p > 0.025). We did not find differences between the NW and
OW children/adolescents in the SAFA-D scales (SAFA-D Tot:
F = 1.302; p > 0.025; Table 3).
Association Between Body Weight and the
Frequency of Migraine Attacks
High frequency patients were more common in the OW
group (64.7%) than among the NW patients (35.3%; OR
2,5; CI 1.1–6.3; p < 0.05). In contrast, 61.7% of the LF
patients showed normal body weight, while 38.3% was
overweight (Table 1). There were no gender differences
between the HF and LF patients (60% females and 40%
males vs. 53% females vs. 47% males, respectively; χ2 = 0.49;
p > 0.05), and between the NW and OW children/adolescents
(55% females and 45% males vs. 60% females and 40%
males, respectively; χ2 = 0.32; p > 0.05). Also, the age was
not different between the HF and LF patients (11.8 ± 2.4 years
TABLE 2 | Anxiety and depression symptoms in patients with high and low
frequency of attacks.
Low
frequency
TABLE 1 | Distribution of patients according to weight and frequency of attacks.
Normal
weight
Overweight
Total
Count
% within weight
% within frequency
Count
% within weight
% within frequency
Count
% within weight
% within frequency
Low
frequency
High
frequency
Total
37
67.3%
18
32.7%
55
100.0%
61.7%
23
41.1%
38.3%
60
54.1%
100.0%
35.3%
33
58.9%
64.7%
51
45.9%
100.0%
49.5%
56
100.0%
50.5%
111
100.0%
100.0%
Frontiers in Psychology | www.frontiersin.org
High
frequency
Etasquared
p
SAFA scales
Mean ± SD Mean ± SD
SAFA-A generalized anxiety
SAFA-A social anxiety
SAFA-A separation anxiety
SAFA-A scholastic anxiety
SAFA-A total anxiety
SAFA-D depressed mood
SAFA-D anhedony
SAFA-D touchy mood
SAFA-D sense of
inadequacy
SAFA-D insecurity
SAFA-D feeling of guilt
SAFA-D hopelessness
SAFA-D total depression
7.4 ± 4.7
5.9 ± 4.5
6.2 ± 4.3
7.0 ± 4.9
26.4 ± 15.1
3.1 ± 2.9
1.6 ± 1.7
5.2 ± 3.4
2.7 ± 3.0
11.3 ± 5.8
8.9 ± 5.3
8.6 ± 4.8
10.2 ± 5.6
38.2 ± 16.8
4.2 ± 3.9
2.4 ± 2.5
6.6 ± 4.2
2.8 ± 3.1
0.12
0.09
0.06
0.08
0.122
0.02
0.03
0.18
0.07
0.000*
0.001*
0.006*
0.002*
0.000*
0.133
0.065
0.070
0.943
5.8 ± 3.6
3.3 ± 2.8
2.0 ± 2.5
24.3 ± 15.2
7.2 ± 3.9
4.2 ± 2.6
2.4 ± 3.2
31.7 ± 19.5
0.03
0.02
0.07
0.21
0.063
0.116
0.489
0.042
*Statistically significant differences.
4
October 2020 | Volume 11 | Article 530911
Tarantino et al.
Pediatric Migraine, Weight, Emotional Factors
of attacks and progression from episodic to chronic migraine
(Bigal et al., 2006; Bigal and Lipton, 2006; Pinhas-Hamiel
et al., 2008; Kinik et al., 2010; Winter et al., 2012; Ravid
et al., 2013; Ornello et al., 2015). Moreover, some studies
suggested the role of BMI reduction in migraine outcome,
both in the adult and pediatric age (Hershey et al., 2009;
Bond et al., 2011; Novack et al., 2011; Verrotti et al., 2013).
Interestingly, our results may have clinical implications for
the management and treatment of pediatric migraine. Children
and adolescents with recurrent headaches may require
prophylactic therapy, which is usually prolonged for some
months (Papetti et al., 2019). Most drugs currently used for
migraine prophylaxis, such as amitriptyline and flunarizine,
can lead to body weight increase (Young and Rozen, 2005;
Silberstein, 2015). Since the BMI increase can worsen migraine,
as confirmed by the present study, this factor should be taken
into account, especially when the pharmacological treatment
is associated with a paradoxical increase in the frequency
of attacks. In these cases, the clinician should consider the
use of other classes of drugs that do not interfere with
body weight.
Among our patients, those suffering from a high frequency
of attacks had a higher total anxiety, as compared to those
with low frequency. In particular, the anxiety scores were higher
in all SAFA-A subscales, showing that the children/adolescents
with a high frequency of migraine attacks may experience
more anxious feelings in several fields of life, such as social
relationships, school, and separation from parents. Our results
are in line with the previous evidence, describing children
with migraine as shy, withdrawn, fearful of failure, and needing
approval (Cunningham et al., 1987; Tarantino et al., 2017).
Moreover, young migraineurs are more prone to anxiety
symptoms and less able to cope with stress (Cunningham et al.,
1987; Powers et al., 2006; Antonaci et al., 2011). Although
the precise nature of the headache-anxiety-depression association
is still unknown, the migraine course is probably influenced
by these psychological symptoms (Merikangas et al., 1990;
Guidetti et al., 1998; Antonaci et al., 2011).
To date, the psychological profile of overweight children
and adolescents with migraine has not been investigated. In
adults, Tietjen et al. (2007) showed that, among the patients
seeking treatment for headache, anxiety, and depression were
more common in obese patients than in non-obese ones. In
our sample, the OW patients had higher symptoms of separation
anxiety, as compared to the NW patients.
Previous studies showed the role of separation anxiety
symptoms and attachment style on migraine clinical features
in pediatric samples (Esposito et al., 2013; Tarantino et al.,
2013, 2017; Faedda et al., 2018). There is also evidence that
the attachment insecurity and mother-child relationship are
involved in the emotional regulation and subsequent eating
behavior (Strauss et al., 1985; Brødsgaard et al., 2014). In
our study, the association between migraine, overweight, and
separation anxiety symptoms may be due to the common
psychological vulnerability factors. Migraine and obesity may
share an increased risk for internalizing disorders, difficulties
in emotional regulation, and dysfunctional mother-child
TABLE 3 | Anxiety and depression symptoms in normal and overweight
patients.
Normal
weight
Overweight
SAFA scales
Mean ± SD
Mean ± SD
SAFA-A generalized anxiety
SAFA-A social anxiety
SAFA-A separation anxiety
SAFA-A scholastic anxiety
SAFA-A total anxiety
SAFA-D depressed mood
SAFA-D anhedony
SAFA-D touchy mood
SAFA-D sense of inadequacy
SAFA-D insecurity
SAFA-D feeling of guilt
SAFA-D hopelessness
SAFA-D total depression
9.0 ± 5.6
7.2 ± 5.0
6.0 ± 4.3
8.1 ± 5.7
29.6 ± 16.0
3.4 ± 3.2
1.7 ± 1.8
5.5 ± 3.5
2.7 ± 3.0
6.2 ± 3.7
3.6 ± 2.5
2.0 ± 2.6
25.8 ± 15.4
9.4 ± 5.5
7.4 ± 5.2
8.5 ± 4.8
8.7 ± 5.3
34.0 ± 17.7
3.8 ± 3.6
2.4 ± 2.5
6.3 ± 4.2
2.8 ± 3.1
6.7 ± 3.9
3.8 ± 3.1
2.4 ± 3.2
30.0 ± 20.0
Etasquared
p
0.001
0.000
0.067
0.003
0.017
0.005
0.023
0.011
0.001
0.004
0.001
0.004
0.014
0.736
0.828
0.006*
0.551
0.177
0.494
0.145
0.321
0.798
0.541
0.728
0.525
0.257
*Statistically significant differences.
Anxiety and Depressive Symptoms as
Mediators Between Body Weight and
Frequency of Migraine Attacks
Sobel’s test showed a mediating role between being overweight
and high frequency of attacks for social anxiety (z = 2.04 ± 0.03;
p < 0.05) and total anxiety (z = 2.11 ± 0.03; p < 0.05). No
mediation role was found for depression (z = 0.77 ± 0.02;
p > 0.05), school anxiety (z = 1.86 ± 0.03; p > 0.05), and
separation anxiety (z = 1.64 ± 0.02; p > 0.05).
DISCUSSION
Our study investigated the association between body weight,
migraine frequency, and psychological symptoms. The main
results were as follows: (1) Overweight status was associated
with a high frequency of migraine attacks; (2) there was an
association between the frequency of attacks, anxiety, and
depression total scores; in particular, the HF patients showed
a higher score in every SAFA-A subscale; (3) OW patients
presented with higher symptoms of separation anxiety than
NW patients; and (4) anxiety, in particular social anxiety,
mediated the association between being overweight and the
severity of migraine.
Over the last years, there has been an increasing interest in
analyzing the association between headache and body weight,
with controversial evidences (Le et al., 2011; Pakalnis and Kring,
2012; Verrotti et al., 2012; Winter et al., 2012; Chai et al., 2014b;
Oakley et al., 2014; Ravid, 2014; Eidlitz-Markus et al., 2015).
The results of our study, showing an association between
the overweight status and high frequency of migraine attacks,
confirms the possible interaction between weight and migraine
severity (Bigal et al., 2006; Bigal and Lipton, 2006; Winter
et al., 2012; Oakley et al., 2014; Ornello et al., 2015). Several
studies on adult populations showed that obesity and overweight
may be involved in migraine progression. In particular, a
high BMI and obesity lead to an increase in the frequency
Frontiers in Psychology | www.frontiersin.org
5
October 2020 | Volume 11 | Article 530911
Tarantino et al.
Pediatric Migraine, Weight, Emotional Factors
interaction (Strauss et al., 1985; Strauss, 2000; Fichtel and
Larsson, 2002; Antonaci et al., 2011; Brødsgaard et al., 2014;
Tarantino et al., 2018). We hypothesize that overweight
children with migraine may have low self-esteem and life
satisfaction (Danielsen et al., 2012; Nazeri et al., 2018) so
that they may feel more shy and hopeless and may be more
prone to seek support from caregivers. From another
perspective, the higher levels of separation anxiety symptoms
in our young overweight patients may be related to a maternal
maladaptive caring behavior. In a previous study, we found
that the mothers of children suffering from migraine may
show difficulties in understanding and detecting their own
emotions and other people’s emotions (Tarantino et al., 2018).
They may also appear less empathic to their children’s
psychological needs and affectively less involved in the
relationship with them (Tarantino et al., 2018). Moreover,
we found an association between these maternal psychological
factors (alexithymia) and anxiety symptoms, including
separation anxiety, in their migraine children (Tarantino
et al., 2018). From this point of view, in the present OW
patients, the caregivers’ inability to decode and cope with
their children’s needs, emotional requests, and pain signals
may increase the children’s anxiety and lead mothers to use
an inappropriate feeding behavior as a successful tool for
calming or as a source of relationship (Evers et al., 2010;
van Strien et al., 2013).
Very few studies explored the interaction between the
psychological factors, body weight, and headache severity.
Literature data showed that migraine and obesity share similar
psychological features, such as anxiety, mood, and stress related
disorders (Cunningham et al., 1987; Guidetti et al., 1998; Strauss,
2000; Fichtel and Larsson, 2002; Danielsen et al., 2012; Nazeri
et al., 2018). Obese children and adolescents show low selfesteem, social anxiety, and social isolation (Strauss, 2000; Fichtel
and Larsson, 2002; Danielsen et al., 2012). They may very
often undergo stigmatization (Fichtel and Larsson, 2002). As
discussed above, the same psychological characteristics have
been described also in children with migraine (Cunningham
et al., 1987; Masruha et al., 2012). In adult patients, a significant
interaction was found between some psychological factors, such
as depression/anxiety, coping style, stress, migraine frequency,
and being overweight (Tietjen et al., 2007; Bond et al., 2015;
Galioto et al., 2017). A previous study investigated the relationship
of childhood headache with depression, anxiety, and eating
habits but it did not consider the children’s weight status
according to the BMI (Bektaş et al., 2015).
In the present study, mediation analysis showed that the
anxiety symptoms, in particular social anxiety, may be a
vulnerability factor influencing not only the frequency of
migraine attacks but also the relationship between weight
and migraine severity. Social anxiety may include emotional,
behavioral, and physical symptoms (American Psychiatric
Association, 2013). It is a condition characterized by an
excessive and inappropriate worry about social situations, fear
of being negatively evaluated, criticized, or rejected by others.
Social anxiety is characterized by higher levels of distress
and may interfere with daily routine, school, or other social
Frontiers in Psychology | www.frontiersin.org
activities (American Psychiatric Association, 2013). Previous
literature data showed a high level of social anxiety in children
suffering from migraine (Vulić-Prtorić et al., 2007). In particular,
there is evidence that children with migraine, being more
afraid of hurting themselves (Vulić-Prtorić et al., 2007), can
more often get involved in solitary activities and are described
as having a fewer peer relationship. We can hypothesize that,
in our sample, social anxiety may be amplified by being
overweight, causing in children the perception of feeling less
“acceptable” and less able to meet social expectations. The
difficult relationship with their own body weight would,
therefore, influence their social relationships and self-confidence
(Strauss, 2000; Fichtel and Larsson, 2002; Danielsen et al.,
2012), increasing the feelings of hopelessness, isolation, and
frustration. This can promote migraine onset, precipitate, and
aggravate migraine attacks. The repetition of pain episodes
may have a negative impact on the daily activity, as well as
on school and social functioning, leading to the chronification
of pain. Moreover, the repetition of pain episodes may increase
the levels of stress (Merikangas et al., 1990), thus favoring
a dysfunctional feeding behavior as a coping mechanism (van
Strien et al., 2013; Nazeri et al., 2018).
These finding can provide important clinical consequences
for an efficacious treatment program in children with migraine.
Given the significant impact of both being overweight and
anxiety on the migraine course, a special attention should
be given to weight status and psychological symptoms. Detecting
anxiety symptoms, in particular social anxiety, would mitigate
the effect of weight on migraine severity and may reduce the
risk of migraine chronification. A psychological intervention,
such as cognitive-behavioral, may help children with migraine
to identify and modify their negative thoughts about self, and
may improve children’s self-esteem and coping ability. These
may prevent the vicious cycle between weight, anxiety, and
migraine, above mentioned.
Our study has some limitations. First, our sample included
children/adolescents referred into our tertiary headache center,
therefore, they may not be a representative of the pediatric
migraine in the general population. Second, in future studies,
it will be important to differentiate the overweight patients
from the obese ones. Finally, the psychological tools (SAFA-A
and D) used in our study to explore the anxiety and depression
are self-report questionnaires. While they have proven to be valid
instruments for screening, they are not diagnostic for anxiety
and depression.
CONCLUSION
This is the first study investigating the association between
body weight and anxiety/depression in children suffering
from migraine. We found that the anxiety symptoms, in
particular social anxiety, may contribute to the association
between being overweight and migraine severity. Because
of the potential impact that the psychological symptoms
and body weight can have on the migraine outcome, a
systematic evaluation of children and adolescents with
6
October 2020 | Volume 11 | Article 530911
Tarantino et al.
Pediatric Migraine, Weight, Emotional Factors
migraine should include both a psychological screening and
a particular concern about body weight.
consent to participate in this study was provided by the
participants’ legal guardian/next of kin.
DATA AVAILABILITY STATEMENT
AUTHOR CONTRIBUTIONS
The datasets generated for this study are available on request
to the corresponding author.
ST, LP, and MV conceived and designed the study. ST and
ADS collected the data. LP analyzed the data. MANF, VM,
FU, and RM were involved in the data interpretation. LP,
SG, and FV assisted in the preparation of the manuscript.
ST and MV drafted the manuscript and were the main authors.
All authors contributed to the article and approved the
submitted version.
ETHICS STATEMENT
The studies involving human participants were reviewed and
approved by Bambino Gesù Ethics Committee. Written informed
REFERENCES
Danielsen, Y. S., Stormark, K. M., Nordhus, I. H., Mæhle, M., Sand, L.,
Ekornås, B., et al. (2012). Factors associated with low self-esteem in children
with overweight. Obes. Facts 5, 722–733. doi: 10.1159/000338333
Dindo, L. N., Recober, A., Haddad, R., and Calarge, C. A. (2017). Comorbidity
of migraine, major depressive disorder, and generalized anxiety disorder in
adolescents and young adults. Int. J. Behav. Med. 24, 528–534. doi: 10.1007/
s12529-016-9620-5
Eidlitz-Markus, T., Haimi-Cohen, Y., and Zeharia, A. (2015). Association of pediatric
obesity and migraine with comparison to tension headache and samples from
other countries. J. Child Neurol. 30, 445–450. doi: 10.1177/0883073814553975
Esposito, M., Parisi, L., Gallai, B., Marotta, R., Di Dona, A., Lavano, S. M.,
et al. (2013). Attachment styles in children affected by migraine without
aura. Neuropsychiatr. Dis. Treat. 9, 1513–1519. doi: 10.2147/NDT.S52716
Evers, C., Marijn Stok, F., and de Ridder, D. T. (2010). Feeding your feelings:
emotion regulation strategies and emotional eating. Personal. Soc. Psychol.
Bull. 36, 792–804. doi: 10.1177/0146167210371383
Faedda, N., Natalucci, G., Piscitelli, S., Alunni Fegatelli, D., Verdecchia, P., and
Guidetti, V. (2018). Migraine and attachment type in children and adolescents:
what is the role of trauma exposure? Neurol. Sci. 39(Suppl. 1), 109–110.
doi: 10.1007/s10072-018-3368-4
Farello, G., Ferrara, P., Antenucci, A., Basti, C., and Verrotti, A. (2017). The
link between obesity and migraine in childhood: a systematic review. Ital.
J. Pediatr. 43:27. doi: 10.1186/s13052-017-0344-1
Fichtel, A., and Larsson, B. (2002). Psychosocial impact of headache and
comorbidity with other pains among Swedish school adolescents. Headache
42, 766–775. doi: 10.1046/j.1526-4610.2002.02178.x
Franzoni, E., Monti, M., Pellicciari, A., Muratore, C., Verrotti, A., Garone, C.,
et al. (2009). SAFA: a new measure to evaluate psychiatric symptoms detected
in a sample of children and adolescents affected by eating disorders. Correlations
with risk factors. Neuropsychiatr. Dis. Treat. 5, 207–214. doi: 10.2147/ndt.s4874
Friedman, D. I., and De ver Dye, T. (2009). Migraine and the environment.
Headache 49, 941–952. doi: 10.1111/j.1526-4610.2009.01443.x
Galioto, R., O’Leary, K. C., Thomas, J. G., Demos, K., Lipton, R. B., Gunstad, J.,
et al. (2017). Lower inhibitory control interacts with greater pain catastrophizing
to predict greater pain intensity in women with migraine and overweight/
obesity. J. Headache Pain 18:41. doi: 10.1186/s10194-017-0748-8
Genizi, J., Matar, A. K., Schertz, M., Zelnik, N., and Srugo, I. (2016). Pediatric
mixed headache—the relationship between migraine, tension-type headache
and learning disabilities—in a clinic-based sample. J. Headache Pain 17:42.
doi: 10.1186/s10194-016-0625-x
Gilmore, J. (1999). Body mass index and health. Health Rep. 11, 31–43.
Guidetti, V., Galli, F., Fabrizi, P., Giannantoni, A. S., Napoli, L., Bruni, O.,
et al. (1998). Headache and psychiatric comorbidity: clinical aspects and
outcome in an 8-year follow-up study. Cephalalgia 18, 455–462. doi: 10.1046/j.
1468-2982.1998.1807455.x
Headache Classification Committee of the International Headache Society (IHS)
(2013). The international classification of headache disorders, 3rd edition
(beta version). Cephalalgia 33, 629–808. doi: 10.1177/0333102413485658
Hershey, A. D., Powers, S. W., Nelson, T. D., Kabbouche, M. A., Winner, P.,
Yonker, M., et al. (2009). Obesity in the pediatric headache population: a
multicenter study. Headache 49, 170–177. doi: 10.1111/j.1526-4610.2008.01232.x
Abu Bakar, N., Tanprawate, S., Lambru, G., Torkamani, M., Jahanshahi, M.,
and Matharu, M. (2016). Quality of life in primary headache disorders: a
review. Cephalalgia 36, 67–91. doi: 10.1177/0333102415580099
Albuquerque, D., Nóbrega, C., Manco, L., and Padez, C. (2017). The contribution
of genetics and environment to obesity. Br. Med. Bull. 123, 159–173. doi:
10.1093/bmb/ldx022
American Psychiatric Association (2013). Diagnostic and statistical manual of
mental disorders. 5th Edn. Washington, D.C.: American Psychiatric Association.
Antonaci, F., Nappi, G., Galli, F., Manzoni, G. C., Calabresi, P., and Costa, A.
(2011). Migraine and psychiatric comorbidity: a review of clinical findings.
J. Headache Pain 12, 115–125. doi: 10.1007/s10194-010-0282-4
Apovian, C. M. (2016). Obesity: definition, comorbidities, causes, and burden.
Am. J. Manag. Care 22(Suppl. 7), s176–s185.
Bektaş, Ö., Uğur, C., Gençtürk, Z. B., Aysev, A., Sireli, Ö., and Deda, G.
(2015). Relationship of childhood headaches with preferences in leisure time
activities, depression, anxiety and eating habits: a population-based, crosssectional study. Cephalalgia 35, 527–537. doi: 10.1177/0333102414547134
Bellini, B., Arruda, M., Cescut, A., Saulle, C., Persico, A., Carotenuto, M.,
et al. (2013). Headache and comorbidity in children and adolescents.
J. Headache Pain 14:79. doi: 10.1186/1129-2377-14-79
Bigal, M. E., Liberman, J. N., and Lipton, R. B. (2006). Obesity and migraine: a
population study. Neurology 66, 545–550. doi: 10.1212/01.wnl.0000197218.05284.82
Bigal, M. E., and Lipton, R. B. (2006). Obesity is a risk factor for transformed
migraine but not chronic tension-type headache. Neurology 67, 252–257.
doi: 10.1212/01.wnl.0000225052.35019.f9
Bond, D. S., Buse, D. C., Lipton, R. B., Thomas, J. G., Rathier, L., Roth, J.,
et al. (2015). Clinical pain catastrophizing in women with migraine and
obesity. Headache 55, 923–933. doi: 10.1111/head.12597
Bond, D. S., Roth, J., Nash, J. M., and Wing, R. R. (2011). Migraine and
obesity: epidemiology, possible mechanisms, and the potential role of weight
loss treatment. Obes. Rev. 12, e362–e371. doi: 10.1111/j.1467-789X.2010.00791.x
Brødsgaard, A., Wagner, L., and Poulsen, I. (2014). Childhood overweight dependence
on mother-child relationship. Health Psychol. Res. 2:1583. doi: 10.4081/hpr.2014.1583
Cacciari, E., Milani, S., Balsamo, A., Spada, E., Bona, G., Cavallo, L., et al.
(2006). Italian cross-sectional growth charts for height, weight and BMI (2
to 20 yr). J. Endocrinol. Invest. 29, 581–593. doi: 10.1007/BF03344156
Chai, N. C., Bond, D. S., Moghekar, A., Scher, A. I., and Peterlin, B. L. (2014a).
Obesity and headache: part II—potential mechanism and treatment
considerations. Headache 54, 459–471. doi: 10.1111/head.12297
Chai, N. C., Scher, A. I., Moghekar, A., Bond, D. S., and Peterlin, B. L. (2014b).
Obesity and headache: part I—a systematic review of the epidemiology of
obesity and headache. Headache 54, 219–234. doi: 10.1111/head.12296
Cianchetti, C., and Sannio Fascello, G. (2001). Scale Psichiatriche di
Autosomministrazione per Fanciulli e Adolescenti (SAFA). Firenze:
Organizzazioni Speciali.
Cunningham, S. J., McGrath, P. J., Ferguson, H. B., Humphreys, P., D’Astous, J.,
Latter, J., et al. (1987). Personality and behavioural characteristics in pediatric
migraine. Headache 27, 16–20. doi: 10.1111/j.1526-4610.1987.hed27
01016.x
Frontiers in Psychology | www.frontiersin.org
7
October 2020 | Volume 11 | Article 530911
Tarantino et al.
Pediatric Migraine, Weight, Emotional Factors
Kinik, S. T., Alehan, F., Erol, I., and Kanra, A. R. (2010). Obesity and pediatric
migraine. Cephalalgia 30, 105–109. doi: 10.1111/j.1468-2982.2009.01907.x
Kyungmi, O., Soo-Jin, C., Yun Kyung, C., Jae-Moon, K., and Min Kyung, C.
(2014). Combination of anxiety and depression is associated with an increased
headache frequency in migraineurs: a population-based study. BMC Neurol.
14:238. doi: 10.1186/s12883-014-0238-4
Le, H., Tfelt-Hansen, P., Skytthe, A., Kyvik, K. O., and Olesen, J. (2011).
Association between migraine, lifestyle and socioeconomic factors: a populationbased cross-sectional study. J. Headache Pain 12, 157–172. doi: 10.1007/
s10194-011-0321-9
Lipton, R. B., and Bigal, M. E. (2005). Migraine: epidemiology, impact, and
risk factors for progression. Headache 45(Suppl. 1), S3–S13. doi: 10.1111/j.
1526-4610.2005.4501001.x
Malone, C. D., Bhowmick, A., and Wachholtz, A. B. (2015). Migraine: treatments,
comorbidities, and quality of life, in the USA. J. Pain Res. 8, 537–547. doi:
10.2147/JPR.S88207
Marmura, M. J. (2018). Triggers, protectors, and predictors in episodic migraine.
Curr. Pain Headache 22:81. doi: 10.1007/s11916-018-0734-0
Masruha, M. R., Lin, J., Minett, T. S., Vitalle, M. S., Fisberg, M., Vilanova, L. C.,
et al. (2012). Social anxiety score is high in adolescents with chronic migraine.
Pediatr. Int. 54, 393–396. doi: 10.1111/j.1442-200X.2011.03555.x
Merikangas, K. R., Angst, J., and Isler, H. (1990). Migraine and psychopathology.
Results of the Zurich cohort study of young adults. Arch. Gen. Psychiatry
47, 849–853. doi: 10.1001/archpsyc.1990.01810210057008
Nazeri, M., Ghahrechahi, H. R., Pourzare, A., Abareghi, F., Samiee-Rad, S.,
Shabani, M., et al. (2018). Role of anxiety and depression in association
with migraine and myofascial pain temporomandibular disorder. Indian J.
Dent. Res. 29, 583–587. doi: 10.4103/0970-9290.244932
Novack, V., Fuchs, L., Lantsberg, L., Kama, S., Lahoud, U., Horev, A., et al.
(2011). Changes in headache frequency in premenopausal obese women
with migraine after bariatric surgery: a case series. Cephalalgia 31, 1336–1342.
doi: 10.1177/0333102411413162
Oakley, B. C., Scher, A. I., Recober, A., and Lee Peterlin, B. (2014). Headache
and obesity in the pediatric population. Curr. Pain Headache Rep. 18:416.
doi: 10.1007/s11916-014-0416-5
Ornello, R., Ripa, P., Pistoia, F., Degan, D., Tiseo, C., Carolei, A., et al. (2015).
Migraine and body mass index categories: a systematic review and metaanalysis of observational studies. J. Headache Pain 16:27. doi: 10.1186/
s10194-015-0510-z
Öztop, D. B., Taşdelen, B. İ., PoyrazoğLu, H. G., Ozsoy, S., Yilmaz, R., Şahın, N.,
et al. (2016). Assessment of psychopathology and quality of life in children
and adolescents with migraine. J. Child Neurol. 31, 837–842. doi:
10.1177/0883073815623635
Pakalnis, A., and Kring, D. (2012). Chronic daily headache, medication overuse,
and obesity in children and adolescents. J. Child Neurol. 27, 577–580. doi:
10.1177/0883073811420869
Papetti, L., Ursitti, F., Moavero, R., Ferilli, M. A. N., Sforza, G., Tarantino, S.,
et al. (2019). Prophylactic treatment of pediatric migraine: is there anything
new in the last decade? Front. Neurol. 10:771. doi: 10.3389/fneur.2019.00771
Pellicciari, A., Gualandi, S., Iero, L., Monti, M., Di Pietro, E., Sacrato, L., et al.
(2012). Psychometric evaluation of SAFA P test for eating disorders in
adolescents: comparative validation with EDI-2. Eur. Eat. Disord. Rev. 20,
e108–e113. doi: 10.1002/erv.1099
Peterlin, B. L., Rosso, A. L., Rapoport, A. M., and Scher, A. I. (2010). Obesity
and migraine: the effect of age, gender and adipose tissue distribution.
Headache 50, 52–62. doi: 10.1111/j.1526-4610.2009.01459.x
Peterlin, B. L., Rosso, A. L., Williams, M. A., Rosenberg, J. R., Haythornthwaite, J. A.,
Merikangas, K. R., et al. (2013). Episodic migraine and obesity and the
influence of age, race, and sex. Neurology 81, 1314–1321. doi: 10.1212/
WNL.0b013e3182a824f7
Pinhas-Hamiel, O., Frumin, K., Gabis, L., Mazor-Aronovich, K., Modan-Moses, D.,
Reichman, B., et al. (2008). Headaches in overweight children and adolescents
referred to a tertiary-care center in Israel. Obesity 16, 659–663. doi: 10.1038/
oby.2007.88
Powers, S. W., Gilman, D. K., and Hershey, A. D. (2006). Headache and
psychological functioning in children and adolescents. Headache 46,
1404–1415. doi: 10.1111/j.1526-4610.2006.00583.x
Frontiers in Psychology | www.frontiersin.org
Radat, F., and Swendsen, J. (2005). Psychiatric comorbidity in migraine: a
review. Cephalalgia 25, 165–178. doi: 10.1111/j.1468-2982.2004.00839.x
Ravid, S. (2014). Migraine and paediatric obesity: a plausible link? Indian
J. Med. Res. 139, 343–348.
Ravid, S., Shahar, E., Schiff, A., and Gordon, S. (2013). Obesity in children
with headaches: association with headache type, frequency, and disability.
Headache 53, 954–961. doi: 10.1111/head.12088
Silberstein, S. D. (2015). Preventive migraine treatment. Continuum 21, 973–989.
doi: 10.1212/CON.0000000000000199
Strauss, R. S. (2000). Childhood obesity and self-esteem. Pediatrics 105:e15.
doi: 10.1542/peds.105.1.e15
Strauss, C. C., Smith, K., Frame, C., and Forehand, R. (1985). Personal and
interpersonal characteristics associated with childhood obesity. J. Pediatr.
Psychol. 10, 337–343. doi: 10.1093/jpepsy/10.3.337
Tarantino, S., Capuano, A., Torriero, R., Citti, M., Vollono, C., Gentile, S.,
et al. (2014). Migraine equivalents as part of migraine syndrome in childhood.
Pediatr. Neurol. 51, 645–649. doi: 10.1016/j.pediatrneurol.2014.07.018
Tarantino, S., De Ranieri, C., Dionisi, C., Citti, M., Capuano, A., Galli, F.,
et al. (2013). Clinical features, anger management and anxiety: a possible
correlation in migraine children. J. Headache Pain 14:39. doi: 10.1186/
1129-2377-14-39
Tarantino, S., De Ranieri, C., Dionisi, C., Gagliardi, V., Paniccia, M. F., Capuano, A.,
et al. (2017). Role of the attachment style in determining the association
between headache features and psychological symptoms in migraine children
and adolescents. An analytical observational case-control study. Headache
57, 266–275. doi: 10.1111/head.13007
Tarantino, S., Papetti, L., De Ranieri, C., Boldrini, F., Rocco, A. M., D’Ambrosio, M.,
et al. (2018). Maternal alexithymia and attachment style: which relationship
with their children's headache features and psychological profile? Front.
Neurol. 8:751. doi: 10.3389/fneur.2017.00751
Tietjen, G. E., Peterlin, B. L., Brandes, J. L., Hafeez, F., Hutchinson, S.,
Martin, V. T., et al. (2007). Depression and anxiety: effect on the migraineobesity relationship. Headache 47, 866–875. doi: 10.1111/j.1526-4610.
2007.00810.x
Togha, M., Haghdoost, F., Khorsha, F., Razeghi Jahromi, S., and Ghorbani, Z.
(2019). Body mass index and its association with migraine characteristics
in female patients. Arch. Iran. Med. 22, 554–559.
van Strien, T., Cebolla, A., Etchemendy, E., Gutiérrez-Maldonado, J.,
Ferrer-García, M., Botella, C., et al. (2013). Emotional eating and food
intake after sadness and joy. Appetite 66, 20–25. doi: 10.1016/j.appet.2013.02.016
Verrotti, A., Agostinelli, S., D’Egidio, C., Di Fonzo, A., Carotenuto, M., Parisi, P.,
et al. (2013). Impact of a weight loss program on migraine in obese
adolescents. Eur. J. Neurol. 20, 394–397. doi: 10.1111/j.1468-1331.2012.03771.x
Verrotti, A., Di Fonzo, A., Agostinelli, S., Coppola, G., Margiotta, M., and
Parisi, P. (2012). Obese children suffer more often from migraine. Acta
Paediatr. 101, e416–e421. doi: 10.1111/j.1651-2227.2012.02768.x
Vulić-Prtorić, A., Galić, S., Coha, R., Grubić, M., Lopižić, J., and Padelin, P.
(2007). Anxiety in children with headaches. Psychol. Top. 16, 201–224.
Winter, A. C., Wang, L., Buring, J. E., Sesso, H. D., and Kurth, T. (2012).
Migraine, weight gain and the risk of becoming overweight and obese: a
prospective cohort study. Cephalalgia 32, 963–971. doi: 10.1177/033310
2412455708
Young, W. B., and Rozen, T. D. (2005). Preventive treatment of migraine: effect
on weight. Cephalalgia 25, 1–11. doi: 10.1111/j.1468-2982.2004.00819.x
Conflict of Interest: The authors declare that the research was conducted in
the absence of any commercial or financial relationships that could be construed
as a potential conflict of interest.
Copyright © 2020 Tarantino, Papetti, Di Stefano, Messina, Ursitti, Ferilli, Sforza,
Moavero, Vigevano, Gentile and Valeriani. This is an open-access article distributed
under the terms of the Creative Commons Attribution License (CC BY). The
use, distribution or reproduction in other forums is permitted, provided the
original author(s) and the copyright owner(s) are credited and that the original
publication in this journal is cited, in accordance with accepted academic practice.
No use, distribution or reproduction is permitted which does not comply with
these terms.
8
October 2020 | Volume 11 | Article 530911