Attachment Insecurity Mediates Anxiety in Pediatric Migraine

Attachment insecurity may amplify anxiety in children and adolescents with migraine without aura.

According to the results of a case-control study reported in the Journal of Headache and Pain, attachment insecurity may amplify anxiety in children and adolescents with migraine without aura.1

Up to 9.1% of children and adolescents suffer from migraine, which has been linked with psychiatric comorbidities such as anxiety and mood disorders.2-4 Previous studies have found that insecure attachment has an impact on headache frequency and intensity in children and adolescents, as well as anxiety disorders.5

“Attachment is defined as a behavio[u]ral and cognitive system that regulates an individual’s sense of internal security,” explained the researchers in the current study. Attachment security in childhood refers to the “confidence that [the child’s] caregiver will be available and responsive in times of distress,” and is essential for healthy development and psychological resilience.6 The earlier findings suggest that the connection between migraine and anxiety may be partially mediated by attachment insecurity.

To further elucidate these associations, the present study examined attachment security and anxiety in 100 participants age 8 to 18 years with migraine without aura (100% white; 52% girls), compared with 100 healthy controls of similar age and gender. The researchers also evaluated whether maternal and paternal attachment security differentially mediated the link between migraine and anxiety. Attachment security was assessed with the Security Scale, a 15-item self-report measure; anxiety symptoms were assessed with the Self-Administered Psychiatric Scales for Children and Adolescents (SAFA).

The clinical group had significantly higher scores on all anxiety subscales — generalized anxiety disorder, social anxiety disorder, separation and loss anxiety, and scholastic anxiety — compared with healthy controls (P <.001 for all). In addition, lower levels of both maternal and paternal attachment security were observed in the clinical group vs healthy controls, with medium to large effect sizes (d = 0.70) for maternal attachment and very large effect sizes (d = 1.50) for paternal attachment. With this Cohen’s d metric, “values about .5 indicate medium effects, and values above .8 suggest large effects.”

The mediation analysis demonstrated a negative association between migraine and maternal attachment security (β = −.35, P <.0001), and between maternal attachment security and anxiety (β = −.16, P <.03). For paternal attachment security, there was a strong negative association with migraine (β = −.60, P <.0001), but no association with anxiety (β = −.09, t = 1.08, P >.25). 

Taken together, these results support the previously noted relationship between migraine without aura and anxiety in children and adolescents, and they point to attachment insecurity as a mediator of this connection. “These conclusions may buttress the importance of individual psychotherapy as a treatment for anxiety in children and adolescents with migraine, as well as highlight the relevance of psychosocial interventions including family interventions,” the investigators concluded.7

Summary and Clinical Applicability

Attachment insecurity was found to mediate anxiety in children and adolescents with migraine without aura. 


Some of the limitations of the study include a modest sample size and a narrow clinical population in a specific setting. In addition, a convenience sample served as the healthy control group, and this type of sample is subject to biases such as high sampling error and selection bias.

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  1. Williams R, Leone L, Faedda N, et al. The role of attachment insecurity in the emergence of anxiety symptoms in children and adolescents with migraine: an empirical study. J Headache Pain. 2017;18(1):62. doi:10.1186/s10194-017-0769-3
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