Cognitive and emotional mechanisms underlying migraine quality of life

Objective: This study was conducted to examine how migraine-related illness perceptions, shame, and psychological distress are associated with migraine-specific quality of life, and to test a serial mediation model in which illness perceptions relate to quality of life via shame and psychological distress. Background: Migraine is a highly disabling neurological disorder that impairs daily functioning and quality of life. Clinical factors (e.g., attack frequency, duration, and pain) and psychiatric comorbidities explain only part of the variance in quality of life. Guided by the Common-Sense Model of Self-Regulation, we focused on cognitive appraisals of migraine (illness perceptions) and a self-conscious emotion (shame), and their links with psychological distress and quality of life. Methods: In a cross-sectional online survey conducted between March and April 2025, 201 Israeli adults (80% female; mean age ≈40 years) with physician-diagnosed migraine completed self-report measures. Sociodemographic and migraine-related characteristics (years since diagnosis, type, frequency and duration of attacks, pain intensity, and treatment) were assessed, alongside illness perceptions, shame, psychological distress, and migraine-specific quality of life. Results: Participants had lived with migraine for an average of nearly 14 years (mean = 13.6, standard deviation = 10.1), and most experienced at least two monthly attacks, with an average duration of approximately 12 h (mean = 11.9, standard deviation = 15.5). Quality of life scores were in the mid-range (mean = 39.6, standard deviation = 12.1), whereas shame (mean = 1.8, standard deviation = 0.8) and psychological distress (mean = 7.63, standard deviation = 4.89) were relatively low. In regression analysis, the model explained 39% of the variance in quality of life (adjusted [adj.] R² = 0.39, F[8,192] = 16.93, p < 0.001). Higher quality of life was associated with being male (β = 0.12; 95% confidence interval [CI], 0.01–0.23), older age (β = 0.12; 95% CI, 0.01–0.23), shorter attack duration (β = −0.14; 95% CI, −0.26 to −0.02), less severe illness perceptions (β = −0.40; 95% CI, −0.52 to −0.28), and lower psychological distress (β = −0.16; 95% CI, −0.30 to −0.04). Pain intensity (95% CI, −0.20 to 0.05), attack frequency (95% CI, −0.196 to 0.05), and shame (95% CI, −0.19 to 0.05) were not significant independent variables. Mediation analyses showed that illness perceptions were positively related to shame (β = 0.19; 95% CI, 0.03–0.34), and shame was positively related to psychological distress (β = 0.42; 95% CI, 0.30–0.55). The indirect pathways via shame alone (effect = −0.01; 95% CI, −0.05 to 0.01) and via psychological distress alone (effect = 0.01; 95% CI, −0.03 to 0.03) were not significant. However, the serial pathway from illness perceptions to shame, from shame to psychological distress, and from psychological distress to quality of life was significant (indirect effect = −0.01; 95% CI, −0.03 to −0.01), alongside a remaining direct association between illness perceptions and quality of life, indicating a partial serial mediation. Conclusion: Negative illness perceptions and psychological distress are key correlates of poorer quality of life among individuals with migraine, whereas shame appears to be associated with quality of life indirectly via distress. The findings support a biopsychosocial view of migraine and highlight the importance of interventions that target maladaptive illness beliefs and emotional responses, in addition to managing clinical symptoms, to improve daily functioning and quality of life among people living with migraine.