Illness Perception and its Association with Emotional Distress Among Adults with Migraine: A Cross-Sectional Study

Abstract

Background

Migraine is a prevalent and disabling neurological disorder that significantly impairs quality of life. In Pakistan, limited awareness, stigma, and sociocultural misconceptions often delay diagnosis and treatment. Understanding how patients perceive their illness is essential for improving management and outcomes.

Objective

This study explored illness perceptions of migraine among adults in Lahore, Pakistan, and examined their associations with demographic, clinical, and psychological factors.

Methods

A community-based cross-sectional survey was conducted from July to September 2025 using the Brief Illness Perception Questionnaire (B-IPQ). Adults aged 18–70 years with a clinician-diagnosed migraine were recruited through online platforms. Sociodemographic and clinical data were analyzed using SPSS v23. Non-parametric tests and multiple regression analyses were applied to identify correlates and factors independently associated with emotional response.

Results

Of 230 participants, 66.5% were male and 72.2% aged 18–25 years. Psychological and lifestyle factors i.e. stress (11.7%), anxiety (10.8%), and tension (8.7%) were the most frequently perceived causes of migraine. Women and unemployed participants reported significantly higher emotional impact (p < .05). Longer illness duration correlated with stronger chronicity beliefs, and higher attack frequency was linked to greater concern and distress. Regression analysis identified gender, symptom identity, concern, and illness coherence as factors independently associated with emotional response (p < .05).

Conclusion

Negative illness perceptions, particularly heightened concern and emotional reactivity, were correlated with psychological distress among migraine patients. Interventions promoting adaptive illness beliefs and psychoeducation may enhance coping, adherence, and overall quality of life in this population.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1007/s44197-026-00646-4.

Introduction

Migraine is a complex and disabling neurological disorder classified among the primary headache disorders. It is characterized by recurrent attacks of moderate to severe headache, typically unilateral and pulsating in quality, often lasting 4 to 72 h if untreated. These attacks are frequently accompanied by nausea, vomiting, photophobia, and phonophobia, and in some cases are preceded by sensory disturbances known as aura, such as visual flashes, zigzag lines, or paresthesias [1, 2]. Although traditionally considered a headache disorder, current evidence identifies migraine as a broad-spectrum neurological condition with multisystem involvement, including autonomic dysfunction, vestibular symptoms, and cognitive impairment during and between attacks [3, 4].

The disabling nature of migraine substantially impairs quality of life, limiting patients’ ability to perform daily tasks, maintain employment, and participate in social activities [5]. Beyond episodic pain, migraine has been linked with impaired work productivity, increased absenteeism, and diminished social functioning, underscoring its significant societal and economic relevance [6, 7]. As one of the most common neurological conditions globally, migraine affects individuals of all ages, ethnicities, and socioeconomic strata, contributing remarkably to the global burden of disease [8].

The Global Burden of Disease Study 2019 reported that migraine affects over 1.1 billion individuals worldwide and ranks among the leading causes of years lived with disability (YLDs) across all ages, particularly among young and middle-aged adults [9]. Meta-analytic evidence estimates the pooled global prevalence of migraine at approximately 14%, with consistently higher prevalence among women and peak incidence in early adulthood [10]. Biological, hormonal, and psychosocial factors have been proposed to account for these gender differences, with fluctuating sex hormones and sex-specific stress responses influencing migraine susceptibility and chronicity [11, 12].

Furthermore, migraine exhibits a high degree of clinical and psychological comorbidity. Individuals with migraine are more likely than the general population to experience psychiatric disorders such as depression and anxiety, as well as chronic pain syndromes, cardiovascular conditions, and sleep disturbances, which collectively exacerbate disability and complicate management [13–15]. These comorbidities not only magnify disease burden but also influence healthcare utilization and treatment outcomes, emphasizing the multidimensional nature of migraine pathology.

In low- and middle-income countries, including Pakistan, the impact of migraine is further compounded by limited healthcare infrastructure, lack of public awareness, and sociocultural barriers to care [16, 17]. In Pakistan, a countrywide cross-sectional survey found a one-year prevalence of 22.5% among individuals aged 18–65 years, with a larger burden in women [18]. However, most local studies remain restricted to small, hospital-based, or student cohorts, limiting the generalizability of prevalence estimates [19]. Patients often rely on self-medication, over-the-counter analgesics, or traditional remedies, which can delay formal diagnosis and worsen outcomes through medication-overuse headaches [20]. Cultural beliefs attributing headache to stress, weak eyesight, or supernatural causes further reinforce stigma and discourage professional consultation [21].

Illness perception defined as the set of cognitive and emotional representations individuals hold about their illness is an important but underexplored factor in migraine management. Based on Leventhal’s Common-Sense Model, illness perceptions encompass beliefs about identity, causes, consequences, timeline, and controllability of a condition, shaping coping responses, health behaviors, and treatment adherence [22]. Negative illness perceptions, such as viewing migraine as uncontrollable or untreatable, are associated with higher disability, increased psychological distress, and poor adherence to treatment recommendations, whereas more adaptive perceptions support effective coping and better clinical outcomes [23, 24]. Although illness perception has been studied in several chronic pain conditions, including fibromyalgia, low back pain, and orofacial pain [25, 26], evidence regarding its role in migraine especially within low-income settings remains limited.

Given the high prevalence and under-treatment of migraine in Pakistan, coupled with prevailing misconceptions and significant psychosocial comorbidity, understanding illness perceptions is essential to improving disease outcomes. Exploring how patients conceptualize their condition may provide valuable insights into barriers to timely care, treatment adherence, and adaptive coping. Therefore, this study aims to investigate illness perception among adults with migraine in Lahore, Pakistan, and to identify its demographic, clinical, and psychological correlates. Findings from this study will contribute to developing culturally informed awareness campaigns and patient-centered interventions designed to reduce the burden of migraine in the Pakistani population.

Methodology

Study Design

This community-based, quantitative, cross-sectional knowledge, attitude, and perception (KAP) survey carried out in the city of Lahore, Pakistan, using the Brief Illness Perception Questionnaire (B-IPQ) [27]. The authors asked for permission to use this instrument from the copyright holders. The design enabled data collection at a single point in time to capture participants’ cognitive and emotional representations of migraine and examine associations with sociodemographic and clinical variables. Ethical approval was obtained from the Institutional Review Board of Lahore University of Biological and Applied Sciences (Ref: ETH/44/08/25). No personally identifiable information was collected, and all data were anonymized and stored in password-protected files accessible only to the research team.

Adult residents of Lahore aged 18–70 years who had lived in the city for at least six months and were able to read English were eligible to participate. Recruitment was conducted through online community and social media platforms. Participants were included if they reported having received a formal diagnosis of migraine from a licensed healthcare professional (e.g., neurologist, physician, or qualified medical practitioner). At the time of data collection (July–September 2025), migraine diagnoses in routine clinical practice in Pakistan were generally based on the International Classification of Headache Disorders, Third Edition (ICHD-3) criteria as established by the International Headache Society. Participants were therefore required to confirm that their diagnosis had been made by a healthcare professional according to standard diagnostic criteria consistent with ICHD-3.

Given the self-reported nature of the study, diagnostic verification through medical records was not feasible. To enhance diagnostic consistency, the survey additionally included key screening items reflecting core ICHD-3 diagnostic features (e.g., headache duration, unilateral location, associated nausea, photophobia, or phonophobia). Responses were reviewed to ensure alignment with essential migraine criteria.

Participants with other primary or secondary headache disorders, severe psychiatric or neurological conditions, substance-use disorders, incomplete questionnaire responses, or lack of informed consent were excluded initially from the study.

The study analyzed both independent and dependent variables. Independent variables included sociodemographic characteristics (age, gender, marital status, education, occupation, and living arrangements) and clinical features (illness duration, attack frequency, aura presence, and medication use). The dependent variable was the overall B-IPQ score, representing participants’ perceptions of migraine. Higher scores indicated a more negative illness perception.

Sampling Method

This cross-sectional study employed a non-probability convenience sampling technique, supplemented by snowball sampling, to recruit participants, consistent with prior research utilizing the Brief Illness Perception Questionnaire (B-IPQ) in behavioral and health perception studies. The study was conducted between July and September 2025. An electronic survey was distributed through online community groups and social media platforms (e.g., Facebook groups, WhatsApp groups, and relevant health- or student-focused forums and universities) frequented by adult residents of Lahore. The recruitment message briefly described the purpose of the study, the eligibility criteria, and the estimated time required to complete the survey, along with a direct link to the questionnaire hosted on Google Forms. Participants who accessed the link were first presented with a study information sheet outlining the purpose, voluntary nature, confidentiality safeguards, and right to withdraw, followed by an electronic informed consent statement; only those who provided consent were permitted to proceed to the questionnaire. To broaden reach beyond the investigators’ immediate networks, participants were additionally encouraged to share the survey link within their own social circles, consistent with a snowball recruitment strategy. No monetary or material incentive was offered for participation.

The Brief Illness Perception Questionnaire (B-IPQ) was administered in its original English version. At the time of the study, a formally validated Urdu version of the B-IPQ specific to the Pakistani population was not available. Therefore, the questionnaire was not translated.

All participants completed the survey in English. English proficiency was an inclusion criterion, and only individuals able to read and understand English were eligible to participate.

A total of 439 individuals initially completed the survey. Participants were screened using the question, “Have you ever been diagnosed with migraine by a healthcare professional?” Only respondents answering affirmatively were included in the final analysis, yielding 230 eligible cases. Data collection was conducted between July 24 and September 13, 2025.

Although convenience sampling may introduce selection bias and limit population-level generalizability, it remains a pragmatic and commonly employed strategy in public-health and psychosocial research, particularly when investigating patient-reported outcomes and exploratory behavioral constructs [28].

Study Instrument

Data were collected using a structured, self-administered online questionnaire developed in Google Forms. The tool comprised four main sections:

1. Screening Section:

A single question confirmed a prior professional diagnosis of migraine. Only those who responded “Yes” proceeded.

• 2.Sociodemographic Information:

Variables included age, gender, marital status, educational level, occupation, and living arrangements.

• 3.Clinical Characteristics:

Participants reported migraine duration, frequency of attacks, use of preventive medication, history of medication-overuse headache, and the presence of aura or atypical symptoms (e.g., visual or speech disturbances).

• 4.Brief Illness Perception Questionnaire (B-IPQ):

The Brief Illness Perception Questionnaire (Brief IPQ), developed by Broadbent et al. [23], evaluates the cognitive and emotional representations individuals hold about their illness through nine items. The first eight items are rated on a 10-point continuous scale, while the final item invites participants to list the three most significant perceived causes of their condition. To tailor the instrument specifically to migraine, the term “your illness” was replaced with “your headache” in all items. Item 9 invited participants to describe, in their own words, up to three perceived causes of their migraine. These open-text responses were analyzed using conventional content analysis: two reviewers independently read the full set of responses to inductively generate a preliminary coding scheme, which was then refined through discussion until consensus was reached. Terms with overlapping meaning (e.g., “stress,” “tension,” and “mental pressure”) were merged into one category where participants appeared to be using them interchangeably. Because several responses named more than one genuinely distinct cause, a small number of participants were coded into more than one category rather than being forced into a single “most salient” choice. Percentages reported in Table 2 therefore reflect the proportion of the 230 analytic-sample participants who mentioned each cause and do not sum to 100%, as categorization was not mutually exclusive. The first five items assess cognitive aspects of illness perception: “consequences” (item 1; the extent to which the illness affects the patient’s life), “timeline” (item 2; perceived duration of the illness), “personal control” (item 3; perceived control over the illness), “treatment control” (item 4; confidence in the effectiveness of treatment), and “identity” (item 5; perceived severity of symptoms). Items 6 and 8 address emotional components “concern” (the level of worry about the illness) and “emotional response” (the emotional distress caused by the illness) while item 7, “coherence,” measures how well the individual understands their condition. A total Brief IPQ score was counted, with higher scores reflecting a more negative perception of illness. The Brief IPQ has been widely validated across various clinical populations, demonstrating strong concurrent and predictive validity, as well as sensitivity to change following interventions.

Table 2.

Patients’ perceived causes of migraine (open-ended Brief-IPQ item 9)

Perceived cause	n (%)
Stress	27 (11.7)
Mental pressure	12 (5.2)
Workload	10 (4.3)
Tension	20 (8.7)
Anxiety	25 (10.8)
Overthinking	12 (5.2)
Worries	9 (3.9)
Depression	18 (7.8)
Sleep deprivation	8 (3.5)
Irregular sleep	6 (2.6)
Poor sleep quality	3 (1.3)
Headache (general)	14 (6.1)
Severe headache	7 (3.0)
One-sided headache	4 (1.7)
Diet/fast food	6 (2.6)
Caffeine/tea	5 (2.2)
Lack of exercise	3 (1.3)
Smoking	2 (0.9)
Mobile/computer use	4 (1.7)
Bright light	6 (2.6)
Noise	4 (1.7)
Weather changes	2 (0.9)
Pollution	1 (0.4)
Genetic/family history	7 (3.0)
Marital/domestic conflict	3 (1.3)
Relationship issues	2 (0.9)
Hypertension	2 (0.9)
Head trauma	1 (0.4)
Convulsions/epilepsy	1 (0.4)
Other illness/disease	2 (0.9)
Academic pressure	3 (1.3)
Career/job concerns	2 (0.9)
Don’t know/uncertain	11 (4.8)

Participants could describe up to three perceived causes of their migraine in free text; where a response named more than one distinct, non-overlapping cause, it was coded into more than one category

Percentages are therefore calculated as the proportion of the 230 analytic-sample participants (229 of whom provided at least one codable response) who mentioned each cause, and the column does not sum to 100% because categorization was not mutually exclusive

Statistical Analysis

Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 23.0 (SPSS Inc., Chicago, Illinois). Categorical variables were presented as frequencies and percentages. The association between Brief Illness Perception Questionnaire (Brief IPQ) scores and continuous variables such as age and illness duration were examined using Spearman’s rank correlation coefficient. The Mann Whitney U test was employed to compare differences in Brief IPQ scores across dichotomous demographic and clinical characteristics, including gender, marital status, employment status, migraine type (episodic vs. chronic), prophylactic medication use, medication-overuse headache, and presence of aura. All sociodemographic characteristics (age, gender, marital status, education, occupational status, and living situation) and clinical characteristics (migraine pattern, medication-overuse headache, prophylactic medication use, illness duration, and aura status) collected in the study were entered into the regression model together with the seven Brief-IPQ domain scores other than emotional response (which served as the dependent variable), using a simultaneous (“enter”) rather than stepwise entry method, reflecting our a priori interest in the independent contribution of each domain after controlling for demographic and clinical characteristics. Nominal variables with more than two categories and no inherent order — marital status, occupational status, medication-overuse headache, prophylactic medication use, and aura status — were represented using dummy (indicator) variables coded against an explicitly defined reference category (full coding scheme reported in the Table 3 footnote). Ordinal variables with an evenly spaced, natural order (age band, education level, illness-duration band) were retained as ordinal predictors. Given the cross-sectional design, results are reported as factors independently associated with emotional response rather than as predictors.

Table 3.

Factors independently associated with emotional response to migraine (multiple linear regression, N = 230)

Factor	B	Bootstrap SE	p (bootstrap)	95% CI lower	95% CI upper
Gender: Male vs. Female (ref.)	-0.832	0.396	0.036	-1.599	-0.046
Age (ordinal: 18–25 / 26–30 / 31–40 / ≥40)	0.218	0.252	0.371	-0.267	0.731
Education level (ordinal, 6 levels)	-0.163	0.178	0.357	-0.516	0.187
Living situation: Alone vs. With family/others (ref.)	0.868	0.454	0.052	-0.012	1.746
Migraine pattern: Chronic vs. Episodic (ref.)	0.412	0.385	0.268	-0.351	1.168
Illness duration (ordinal, 7 bands)	0.040	0.200	0.823	-0.343	0.442
Marital status: Married vs. Unmarried (ref.)	0.221	0.514	0.661	-0.797	1.231
Marital status: Other (divorced/widowed/undisclosed) vs. Unmarried (ref.)	-0.498	1.341	0.729	-3.166	2.120
Occupation: Unemployed vs. Employed (ref.)	0.005	0.511	0.955	-0.969	1.026
Occupation: Student vs. Employed (ref.)	0.477	0.371	0.212	-0.261	1.191
Occupation: Homemaker vs. Employed (ref.)	0.235	1.050	0.828	-1.812	2.331
Occupation: Disabled/Other vs. Employed (ref.)	0.554	0.675	0.398	-0.768	1.930
Medication-overuse headache: Yes vs. No (ref.)	-0.504	0.368	0.173	-1.210	0.249
Medication-overuse headache: Not sure vs. No (ref.)	-0.416	0.482	0.369	-1.394	0.528
Prophylactic medication: Yes (named class) vs. None (ref.)	-0.365	0.369	0.315	-1.105	0.361
Prophylactic medication: Not sure of name vs. None (ref.)	-0.259	0.609	0.698	-1.437	0.916
Aura: Yes vs. No (ref.)	0.190	0.415	0.674	-0.639	0.986
Aura: Not sure vs. No (ref.)	-0.297	0.533	0.590	-1.323	0.799
Consequences (illness affects life)	0.128	0.089	0.158	-0.049	0.303
Timeline (perceived duration)	0.053	0.084	0.538	-0.115	0.215
Personal control	-0.154	0.081	0.083	-0.304	0.018
Treatment control	0.094	0.079	0.253	-0.063	0.248
Symptom identity	0.219	0.096	0.023	0.030	0.405
Concern	0.188	0.080	0.012	0.041	0.354
Illness coherence (understanding)	0.257	0.077	0.002	0.108	0.412

Model: R² = 0.495, Adjusted R² = 0.433, F(25, 204) = 7.99, p < .001

All nominal variables with more than two categories (marital status, occupational status, medication-overuse headache, prophylactic medication use, aura status) were entered as sets of dummy-coded indicator variables against the stated reference category; the reference category for each set is denoted “(ref.)”

Ordinal variables with an inherent, evenly-spaced ordering (age band, education level, illness-duration band) were retained as ordinal predictors, consistent with standard practice

Coefficients (B), standard errors, and 95% confidence intervals are bias-corrected bootstrap estimates from 5,000 resamples; p-values are two-tailed bootstrap p-values

Bold rows indicate p < .05

For comparisons involving more than two independent groups (e.g., educational level, occupational status), the Kruskal–Wallis test was applied. Because the primary outcome was illness perception measured on a continuous scale using the Brief Illness Perception Questionnaire, the minimum sample size was calculated with the single-mean estimation formula:

Assuming a 95% confidence level (Z = 1.96), an expected standard deviation of 3.0 (a conservative estimate for 0–10 B-IPQ ratings), and a desired precision of ± 0.5 points around the mean score, the required minimum sample size was 139 participants. The final analytic sample of 230 participants exceeded this requirement, providing adequate precision for estimating illness perception among adults with migraine in Lahore.

Emotional response served as the dependent variable in the regression model. All statistical tests were two-tailed, and a p-value ≤ 0.05 was considered statistically significant.

Results

Study Sample

A total of 230 patients diagnosed with migraine were included in the present study. The majority of participants were men (66.5%), and most belonged to the age group of 18–25 years (72.2%). With regard to marital status, 77.8% had never been married, while 22.2% were either married, divorced, or widowed. Most participants were university graduates (63.0%), whereas 34.8% were employed, 12.2% unemployed, and the remainder retired, disabled, or homemakers. The vast majority of participants lived with family or other people (88.3%), whereas only 11.7% reported living alone. Demographic and clinical characteristics of the study population are summarized in Table 1.

Table 1.

Patients’ demographic and Clinical characteristics (N = 230)

Characteristics	N (%)	Characteristics	N (%)
Gender		Pattern of migraine
Female	77 (33.5)	Episodic	184 (80.0)
Male	153 (66.5)	Chronic	46 (20.0)
Age (years)		Medication-overuse headache (doctor-reported)
18–25	166 (72.2)	Yes	106 (46.1)
26–30	40 (17.4)	No	86 (37.4)
31–40	15 (6.5)	Not sure	38 (16.5)
≥ 40	9 (3.9)	Use of prophylactic medication
Marital status		Antidepressants	44 (19.1)
Married	43 (18.7)	Beta-blockers	17 (7.4)
Unmarried	179 (77.8)	Anti-seizure medicines	8 (3.5)
Divorced/Separated	2 (0.9)	Anxiolytics	22 (9.6)
Widow	1 (0.4)	Neuroleptics	6 (2.6)
Prefer not to say	5 (2.2)	Calcium channel blockers	5 (2.2)
Educational status		Other medicines	31 (13.5)
No formal education	3 (1.3)	Not sure	23 (10.0)
Primary school	8 (3.5)	No medication	74 (32.2)
Lower secondary school (middle)	5 (2.2)	Illness duration (years)
High school (intermediate)	48 (20.9)	< 10 years	180 (78.3)
University (Bachelor’s)	145 (63.0)	10–19 years	21 (9.1)
Postgraduate (Master’s/PhD or equivalent)	21 (9.1)	20–29 years	20 (8.7)
Occupational status		30–39 years	4 (1.7)
Employed	80 (34.8)	40–49 years	1 (0.4)
Unemployed	28 (12.2)	50–59 years	2 (0.9)
Student	98 (42.6)	≥ 60 years	2 (0.9)
Housewife	10 (4.3)	Occurrence of aura during migraine attacks
Disabled	3 (1.3)	Yes	143 (62.2)
Others	11 (4.8)	No	52 (22.6)
Living situation		Not sure	35 (15.2)
Living with family/others	203 (88.3)
Living alone	27 (11.7)

Perceived Causes of Migraine

Of the 230 participants in the analytic sample, 229 provided a codable free-text response to the open-ended causal item of the Brief Illness Perception Questionnaire. Because several responses named more than one distinct perceived cause (e.g., ‘stress, anxiety, sleep disturbance’), a small number of participants were coded into more than one category; overlapping terms (e.g., ‘stress,’ ‘tension,’ ‘mental pressure’) were merged into a single category, while genuinely distinct causes were retained separately. Percentages in Table 2 are therefore calculated using N = 230 as the denominator and do not sum to 100%, as categorization was not mutually exclusive. Most responses were related to psychological and lifestyle factors. The most frequently reported cause was stress (11.7%), followed by anxiety (10.8%), tension (8.7%), and depression (7.8%). Other commonly perceived triggers included sleep disturbances, dietary factors, bright light, and heredity or family history etc. are shown in Table 2.

Dimensions of Illness Perception

Mean scores of all eight Brief-IPQ items are presented in Fig. 1, which displays the full 0–10 scale and distinguishes domains by their interpretive direction. Patients reported moderate perceptions of illness consequences (M = 4.17 ± 2.61) and illness duration (M = 3.78 ± 2.48). Perceived personal control (M = 4.75 ± 2.62) and treatment control (M = 5.11 ± 2.89) were relatively higher, suggesting that patients felt a reasonable level of influence over managing their illness and its treatment. Symptom identity was moderate (M = 4.61 ± 2.53). Concern about migraine was prominent (M = 5.33 ± 2.91), as was illness coherence (M = 5.36 ± 2.73) and emotional response (M = 5.30 ± 2.78). Because Brief-IPQ domains do not share a common interpretive direction, higher personal control, treatment control, and coherence scores reflect more adaptive perceptions, whereas higher consequences, timeline, identity, concern, and emotional-response scores reflect greater perceived burden, we report and interpret each domain individually rather than characterizing the overall profile as balanced.

Fig. 1.

Mean Brief-IPQ domain scores among migraine patients (N= 230). Note: Error bars represent ± 2 standard deviations. Red bars indicate dimensions where a higher score reflects a greater perceived burden (Consequences, Timeline, Identity, Concern, Emotional Response); blue bars indicate dimensions where a higher score reflects greater perceived control or understanding (Personal Control, Treatment Control, Coherence)

Association Between Illness Perception and Demographic Characteristics

Due to non-normal distribution of data, non-parametric analyses were performed. Women reported a significantly higher emotional impact of migraine compared to men (U = 4128.5, Z = − 3.72, p < .001). Educational level, marital status, and living situation were not associated with significant differences in any IPQ domain.

However, a significant effect was observed for occupational status (χ² = 12.18, p = .032), with unemployed and disabled participants reporting greater emotional impact than those who were employed. No other sociodemographic variables were significantly associated with illness perceptions.

Association Between Illness Perception and Clinical Characteristics

Spearman’s correlation revealed that longer illness duration was not significantly associated with beliefs about the illness timeline (ρ = 0.10, p = .132).

In contrast, no significant associations were found between illness perception and medication-overuse headache, prophylactic medication use, migraine pattern (episodic vs. chronic), or aura symptoms. These results suggest that, in this sample, illness duration and the objective clinical features examined were not strongly associated with how patients perceived their illness, and that other factors not captured by these clinical variables may play a greater role in shaping illness perceptions.

Factors Independently Associated with Emotional Response

Prior to interpretation, the assumptions underlying the multiple regression model were re-examined for the revised, dummy-coded specification. Multicollinearity was assessed using variance inflation factors (VIF); all values remained below 2.5, indicating no problematic multicollinearity among predictors. Independence of residuals was confirmed via the Durbin-Watson statistic (d = 1.76), within the acceptable range of 1.5–2.5. Standardized residuals ranged from − 2.42 to 2.83, with no extreme outliers, and Cook’s Distance ranged from < 0.001 to 0.077, well below the conventional cutoff of 1.0. These diagnostics supported the appropriateness of the revised model for the data.

Multiple regression analysis was conducted to identify factors independently associated with the emotional impact of migraine, using dummy-coded indicator variables for all nominal predictors with more than two categories (Table 3).

The overall model was statistically significant and explained a moderate proportion of the variance in emotional response (R² = 0.495, Adjusted R² = 0.433, F(25, 204) = 7.99, p < .001). Gender was significantly associated with emotional response (B = − 0.83, bootstrap 95% CI − 1.60 to − 0.05, p = .036), with women reporting greater emotional response than men. Among the illness perception domains, symptom identity (B = 0.22, 95% CI 0.03 to 0.40, p = .023), concern (B = 0.19, 95% CI 0.04 to 0.35, p = .012), and illness coherence (B = 0.26, 95% CI 0.11 to 0.41, p = .002) were significantly associated with emotional distress (Fig. 2). Personal control approached but did not reach significance (B = − 0.15, 95% CI − 0.30 to 0.02, p = .083). No other demographic or clinical dummy-coded categories including marital status, occupational status, medication-overuse headache, prophylactic medication use, or aura status were significantly associated with emotional response.

Fig. 2.

Predictors of emotional response to migraine based on regression analysis

Discussion

We studied illness perceptions in migraine patients and their associations with demographic and clinical features, as well as psychological distress. Our findings show that perceptions of migraine particularly concern, identity, and coherence play an important role in shaping the emotional burden experienced by patients.

Psychological and lifestyle factors such as stress, anxiety, tension, and depression were the most frequently reported perceived causes of migraine. This is consistent with earlier reports by Sirri et al. (2018) [29], who found that stress, heredity, and psychological factors were the most common attributions among migraine patients. The predominance of psychological attributions suggests that patients often conceptualize migraine not only as a neurological disorder but also as a condition strongly linked to emotional and behavioral influences.

Women in our study reported significantly greater emotional impact of migraine compared to men, which mirrors the findings of Sirri et al. (2018) [29] and Acikgoz et al. (2023) [30], who observed higher illness perception scores and greater psychological burden in women with headache disorders. Occupational status was also significantly associated with illness perception, with unemployed and disabled individuals reporting higher emotional distress compared to employed participants. This finding suggests that socioeconomic disadvantage may amplify the psychological impact of migraine, in line with the broader literature highlighting social determinants of health in chronic illness.

In terms of clinical characteristics, illness duration was not significantly associated with beliefs about illness timeline in our sample (ρ = 0.10, p = .132), suggesting that longer-term experience with migraine did not translate into stronger expectations of chronicity in this population. Similarly, no significant associations were observed between illness perception and medication-overuse headache, prophylactic medication use, migraine pattern (episodic vs. chronic), or aura symptoms, suggesting that the clinical characteristics assessed in this study were not strong determinants of how patients perceived their illness. This contrasts with some prior work, such as Kristoffersen et al. (2018) [31], who found that greater headache frequency was linked to more negative illness representations and increased psychological burden; because attack frequency was not directly measured in the present study, we were unable to evaluate this specific relationship, and future studies should incorporate validated headache-frequency measures to clarify its role in illness perception.

Prior work grounded in the Common-Sense Model of illness representation, including that of Sirri et al. (2018) [29] and Acikgoz et al. (2023) [30], has linked maladaptive illness perceptions to increased psychiatric comorbidity in migraine, underscoring the potential relevance of illness perception-focused interventions in this population. Regression analysis revealed that female gender, symptom identity, concern, and illness coherence independently associated with greater emotional burden. Interestingly, higher illness coherence, which reflects a better understanding of the illness, was also correlated with emotional distress. Similar contrasting findings have been reported in other chronic conditions, where increased awareness of illness is associated with higher psychological burden in patients with limited coping resources [23]. This underscores the complexity of the relationship between insight and emotional well-being in migraine. The results are likely generalizable to similar urban outpatient populations in low- and middle-income settings. However, caution is warranted when extrapolating findings to rural or less-educated populations with differing healthcare access or cultural beliefs.

Taken together, our findings suggest that negative illness perceptions are not merely consequences of migraine but are closely connected with emotional burden and reduced quality of life. Because the cross-sectional design does not permit causal inference, this association should be interpreted as correlational rather than directional. Addressing maladaptive perceptions through psychoeducation or cognitive-behavioral interventions may nonetheless be a valuable adjunct to pharmacological treatment in migraine management. Future longitudinal studies are needed to clarify the temporal and potentially causal relationships among these variables and to test whether interventions targeting illness perceptions improve clinical and psychological outcomes. An unexpected finding in the present study was the predominance of male participants, despite the well-established higher prevalence of migraine among women. This imbalance likely reflects recruitment bias associated with online and social media–based sampling rather than true epidemiological distribution. In Pakistan, gender differences in internet access, digital engagement, and willingness to participate in online research may have contributed to disproportionate male representation. The results should therefore be interpreted as reflective primarily of an urban, digitally engaged male subset of migraine patients rather than the broader migraine population.

From a public health and policy perspective, the findings of this study highlight the need to integrate illness perception focused strategies into migraine management frameworks in Pakistan and similar low- and middle-income settings. Targeted interventions like structured patient education, culturally appropriate awareness campaigns, and cognitive-behavioral approaches should be integrated into primary healthcare services because maladaptive perceptions, in particular heightened concern, negative emotional responses, and symptom misattribution, are co-linked with psychological distress. Training healthcare providers to assess and address illness perceptions during routine consultations may improve patient provider communication, treatment adherence, and health outcomes. Additionally, public health programs should prioritize community-level education to reduce stigma, correct misconceptions about migraine etiology, and promote early care-seeking behaviors. Integration of migraine education into existing non-communicable disease (NCD) programs and mental health initiatives could offer a cost-effective and scalable strategy. Policymakers should also consider improving access to multidisciplinary care, including psychological support services, particularly in urban outpatient settings where the burden of migraine is substantial. Collectively, these measures may contribute to reducing the overall disease burden and improving quality of life among individuals with migraine.

Future research should prioritize gender-balanced sampling and examine sex-specific differences in illness perception to enhance external validity. The use of online recruitment through academic and social media platforms may have introduced selection bias, as participation required internet access, digital literacy, and English proficiency.

Consequently, the sample may overrepresent individuals with higher educational and socioeconomic status, potentially limiting generalizability to the broader Pakistani population, particularly rural or lower-income groups. Illness perceptions are influenced by educational exposure, health literacy, and cultural beliefs; therefore, the patterns observed in this study may differ in less-educated or non-English-speaking populations. Future research should employ stratified or probability-based sampling methods and include linguistically validated instruments to capture a more socioeconomically diverse population.

In summary, this study provides important insights into the role of illness perceptions in shaping the psychological burden of migraine among adults in an urban Pakistani setting. The findings demonstrate that cognitive and emotional representations of illness particularly concern, symptom identity, and illness coherence are key determinants of emotional distress, beyond traditional clinical characteristics. By highlighting the influence of modifiable perceptual factors, this study underscores the importance of adopting a more holistic, patient-centered approach to migraine management that integrates psychological and behavioral dimensions alongside biomedical care. These findings contribute to the growing body of evidence emphasizing the need to address illness perceptions as part of comprehensive migraine care and offer a foundation for developing targeted interventions aimed at improving coping, treatment adherence, and overall quality of life.

Limitations

This study has several limitations. First, the use of convenience and snowball sampling via online and social media platforms, combined with an English-literacy eligibility requirement, likely introduced selection bias toward an urban, digitally engaged, and more highly educated subgroup, limiting generalizability to the broader Pakistani population, particularly rural, lower-income, or non-English-speaking individuals. Second, the resulting male-predominant sample (66.5%) does not reflect the well-established higher prevalence of migraine among women and should be interpreted with this in mind. Third, migraine diagnosis was self-reported and could not be verified against medical records, although screening items reflecting ICHD-3 criteria were used to support diagnostic consistency. Fourth, attack frequency (e.g., headache days per month) was not directly assessed; migraine pattern (episodic vs. chronic) was collected as a related clinical characteristic but showed no significant association with illness perception domains, and future studies should incorporate validated frequency measures to clarify this relationship. Fifth, the cross-sectional design precludes causal or directional interpretation of the associations observed between illness perception and emotional response; longitudinal studies are needed to clarify temporal and causal pathways. Finally, this study assessed emotional response to migraine using a single item within the Brief Illness Perception Questionnaire rather than validated, standalone measures of anxiety, depression, somatization, or hostility; consequently, we did not examine correlations between illness perception and these broader dimensions of psychological distress, and data collection relied on self-report measures, which may be subject to recall or social desirability bias.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contributions

T.Y., M.U.A., and M.S.I. conceived and designed the study. T.Y. and S.S. were responsible for data collection and participant recruitment via online platforms. M.Z.I. and M.S.I. performed the statistical analysis using SPSS and conducted the multiple regression analyses. T.Y., M.U.A., and K.M.O. wrote the main manuscript text. M.Z.I., K.M.O., and S.S.A. prepared the tables and visualized the data. M.Z.I. supervised the project and provided critical revisions. All authors reviewed and approved the final manuscript.

Funding

The authors thank the Deanship of Scientific Research at King Khalid University for funding this work through the large Groups Program under grant number (RGP2/127/47). The funder contributed in the study design and reviewed the final version of the manuscript prepared for submission.

Data Availability

The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethical Approval and Consent Form

The study protocol, informed consent form, and data collection tools were reviewed and approved by the Ethical Review Committee (ERC) of Lahore University of Biological and Applied Sciences (UBAS). The research was granted ethical clearance under Reference No. ETH/44/08/25. The Committee confirmed that the research meets the ethical standards and principles outlined in the Declaration of Helsinki and complies with institutional guidelines for human subject research. Informed consent was obtained from all participants prior to their inclusion in the study, and participation was voluntary.

Competing interests

The authors declare no competing interests.