Association between psychological factors and headache burden in patients with migraine and tension-type headache: a systematic review and meta-analysis

Purpose: This study systematically reviewed the literature to identify psychosocial variables associated with headache burden including frequency, intensity, duration, disability, and quality of life in individuals with tension-type headache (TTH) and migraine. Methods: A comprehensive search in PubMed/MEDLINE, PsycINFO, and CINAHL identified studies examining psychosocial factors and headache burden. Eligible studies were appraised for quality using the Joanna Briggs Institute checklist. Meta-analyses were performed for depression and anxiety, and certainty of evidence was evaluated using GRADE. Results: Of 965 records screened, 30 studies met the inclusion criteria, including a total of 71 243 participants, identifying 17 psychosocial factors. Meta-analyses showed moderate-certainty evidence for positive associations between depression and anxiety with headache frequency. Narrative synthesis also indicated moderate-certainty evidence for several psychosocial factors across outcomes such as frequency, intensity, and disability, although most were supported by single studies. Which should be considered as a limitation. Other factors showed lower certainty due to methodological limitations or lack of adjusted analyses. Conclusions: This review highlights the relevance of depression, anxiety, fear of pain, and self-efficacy in relation to headache burden in migraine and TTH. Incorporating psychosocial assessment into headache care may improve clinical reasoning and management. Further research should explore targeted interventions tailored to psychosocial profiles. Implications for rehabilitation Psychosocial factors, including depression, anxiety, fear of pain, and self-efficacy, are meaningfully associated with headache frequency, intensity, and disability in people with migraine and tension-type headache. Routine screening for these psychosocial factors may support more comprehensive assessment and clinical reasoning in rehabilitation settings. Rehabilitation professionals, including physiotherapists, rehabilitation physicians, neurologists, general practitioners, psychologists, and other healthcare providers involved in headache management, should consider adopting a biopsychosocial approach to address these psychosocial contributors within multidisciplinary headache care.