Objective: Using the fear-avoidance model (FAM) as a theoretical framework, this study examined the interactions between empirical factors contributing to disability in episodic migraine. It was tested whether pain catastrophizing, fear of attacks, and depressiveness mediate the relationship between pain experience and disability.
Background: Migraine is a prevalent primary headache disorder associated with significant impairment in daily life. Biological and psychosocial factors contribute to its impact; however, a comprehensive model explaining the mechanisms underlying migraine-related disability is still lacking.
Methods: A cross-sectional online survey was conducted between October 2023 and March 2024 to collect sociodemographic and clinical characteristics of patients with episodic migraine. To evaluate the proposed links within the FAM, two confirmatory path analyses were performed. In Model 1, the Pain Disability Index was used to quantitatively measure subjective aspects of disability. In Model 2, the Migraine Disability Assessment questionnaire was used to assess quantitative aspects of disability. Mediators derived from the FAM included: pain experience (attack frequency and pain intensity), dysfunctional cognitive pain processing (pain catastrophizing), and dysfunctional cognitive-affective response to pain (fear of attacks and depressiveness).
Results: Both path analyses demonstrated good model fit. The explained variance of migraine-related disability was 28% (adjusted R2 = 0.28) in both models, indicating large effect sizes. Attack frequency (standardized path coefficient [β] = 0.21, p < 0.001; β = 0.45, p < 0.001), pain intensity (β = 0.27, p < 0.001; β = 0.16, p < 0.001), fear of attacks (β = 0.12, p = 0.006; β = 0.13, p = 0.004), and depressiveness (β = 0.34, p < 0.001; β = 0.12, p = 0.006), were identified as independent predictors of disability in both models (Model 1; Model 2). Consistent with the hypothesis, an indirect pathway from attack frequency and pain intensity to disability via pain catastrophizing, fear of attacks, and depressiveness was observed in both models.
Conclusion: This study emphasizes the important role of (potentially modifiable) dysfunctional cognitive pain processing and provides empirical evidence for the theoretical assumptions of the FAM. Attack frequency, pain intensity, fear of attacks, and depressiveness were found to be independent predictors of subjectively and quantitatively measured disability in episodic migraine. Pain catastrophizing was identified to be a crucial cognitive-affective factor mediating the relationship between pain experience and disability.
Keywords: depression; episodic migraine; fear avoidance model; fear of attacks; interaction; mediation analyses.
© 2025 The Author(s). Headache: The Journal of Head and Face Pain published by Wiley Periodicals LLC on behalf of American Headache Society.