Structural Modeling of Pain Intensity in Adolescents with Migraine: Intolerance of Uncertainty, Perceived Social Support, and the Mediating Role of Anxiety Sensitivity
Downloads
Objective: This study tested a structural equation model of migraine pain intensity, examining whether anxiety sensitivity mediates the effects of intolerance of uncertainty and perceived social support.
Methods and Materials: In a cross-sectional study, 420 adolescents with neurologist-confirmed migraine were recruited from clinics and secondary schools in Tabriz, Iran. Participants completed scales of intolerance of uncertainty, perceived social support, and anxiety sensitivity, and recorded headache pain intensity in numeric-rating diaries. Structural equation modeling with robust estimation was used to test direct and indirect paths; indirect effects were evaluated with bootstrapping.
Findings: Intolerance of uncertainty was positively associated with anxiety sensitivity, whereas perceived social support was negatively associated (β= 0.49 and β= −0.36, respectively; both p<0.001). Anxiety sensitivity predicted higher pain intensity (β = 0.30, p<0.001). Direct paths from intolerance of uncertainty and perceived social support to pain remained significant (β= 0.27 and β= −0.21, p< 0.001). The model showed acceptable fit and explained substantial variance in anxiety sensitivity and pain intensity. Bootstrapped indirect effects via anxiety sensitivity were significant for both intolerance of uncertainty (β= 0.15) and perceived social support (β= −0.11).
Conclusion: Anxiety sensitivity appears to be a key mechanism linking cognitive vulnerability and social resources to migraine pain in adolescence. Interventions that reduce intolerance of uncertainty and anxiety sensitivity and strengthen perceived support may help lower pain intensity in this population.
Downloads
Arruda, M. A., Guidetti, V., Galli, F., Albuquerque, R. C., & Bigal, M. E. (2010). Migraine, tension-type headache, and attention-deficit/hyperactivity disorder in childhood: a population-based study. Postgraduate Medicine, 122(5), 18-26. https://doi.org/10.3810/pgm.2010.09.2197
Bottiroli, S., Rosi, A., Sances, G., Allena, M., De Icco, R., Lecce, S., Vecchi, T., Tassorelli, C., & Cavallini, E. (2023). Social cognition in chronic migraine with medication overuse: a cross-sectional study on different aspects of mentalization and social relationships. The Journal of Headache and Pain, 24(1), 47. https://doi.org/10.1186/s10194-023-01578-1
Cappucci, S., & Simons, L. E. (2015). Anxiety sensitivity and fear of pain in paediatric headache patients. European Journal of Pain, 19(2), 246-252. https://doi.org/10.1002/ejp.542
Carleton, R. N. (2016). Into the unknown: A review and synthesis of contemporary models involving uncertainty. Journal of anxiety disorders, 39, 30-43. https://doi.org/10.1016/j.janxdis.2016.02.007
Cerami, C., Crespi, C., Bottiroli, S., Santi, G. C., Sances, G., Allena, M., Vecchi, T., & Tassorelli, C. (2021). High perceived isolation and reduced social support affect headache impact levels in migraine after the Covid-19 outbreak: A cross sectional survey on chronic and episodic patients. Cephalalgia, 41(14), 1437-1446. https://doi.org/10.1177/03331024211027568
Eccleston, C., Fisher, E., Howard, R. F., Slater, R., Forgeron, P., Palermo, T. M., Birnie, K. A., Anderson, B. J., Chambers, C. T., & Crombez, G. (2021). Delivering transformative action in paediatric pain: a Lancet Child & Adolescent Health Commission. The Lancet Child & Adolescent Health, 5(1), 47-87. https://doi.org/10.1016/S2352-4642(20)30277-7
Falahi Seresht, S., Karimi, P., Fadakar Gabalou, P., Yazdanbakhsh, K., & Karbalaie, M. (2023). Evaluation of Psychometric Properties of the Childhood Anxiety Sensitivity Index. Quarterly Journal of Child Mental Health, 10(3), 1-15. https://doi.org/10.61186/jcmh.10.3.2
Goretzko, D. (2025). How many factors to retain in exploratory factor analysis? A critical overview of factor retention methods. Psychological Methods. https://doi.org/10.1037/met0000733
Groskurth, K., Bluemke, M., & Lechner, C. M. (2024). Why we need to abandon fixed cutoffs for goodness-of-fit indices: An extensive simulation and possible solutions. Behavior Research Methods, 56(4), 3891-3914. https://doi.org/10.3758/s13428-023-02193-3
Habibi Asgarabad, M., Vahabi, Z., Cheung, H. N., Ahmadi, R., Akbarpour, S., Sadeghian, M. H., & Etesam, F. (2024). Perceived social support, perceived stress, and quality of sleep among COVID-19 patients in Iran: assessing measurement invariance of the multidimensional scale of perceived social support across gender and age. Frontiers in Psychiatry, 15, 1337317. https://doi.org/10.3389/fpsyt.2024.1337317
Horne-Moyer, H. (2024). The Association Between Microaggressions, Migraine and Their Relationship to Psychological Distress, Perceived Stress, and Academic Interference Among Post-secondary Students: A Secondary Analysis D'Youville College]. https://www.proquest.com/openview/a647fbe82452a643145ccd023504eb4e/1?pq-origsite=gscholar&cbl=18750&diss=y
Jak, S., Jorgensen, T. D., Verdam, M. G., Oort, F. J., & Elffers, L. (2021). Analytical power calculations for structural equation modeling: A tutorial and Shiny app. Behavior Research Methods, 53(4), 1385-1406. https://doi.org/10.3758/s13428-020-01479-0
Jobst, L. J., Bader, M., & Moshagen, M. (2023). A tutorial on assessing statistical power and determining sample size for structural equation models. Psychological Methods, 28(1), 207. https://doi.org/10.1037/met0000423
Kellier, D. J., de Prado, B. M., Haagen, D., Grabner, P., Raj, N., Lechtenberg, L., Velasquez, G., Hsu, J. Y., Farrar, J. T., & Hershey, A. D. (2023). Validity of self‐reported migraine in adolescents and children. Headache: The Journal of Head and Face Pain, 63(5), 634-641. https://doi.org/10.1111/head.14498
Khoury, J. M., Watt, M. C., & MacLean, K. (2021). Anxiety sensitivity mediates relations between mental distress symptoms and medical care utilization during COVID-19 pandemic. International Journal of Cognitive Therapy, 14(3), 515-536. https://doi.org/10.1007/s41811-021-00113-x
Kjerrumgaard, A., Hvedstrup, J., Carlsen, L. N., Dyre, K., & Schytz, H. (2023). Validation of a Digital Headache Calendar at a tertiary referral center. Diagnostics, 14(1), 21. https://doi.org/10.3390/diagnostics14010021
Kline, R. B. (2023). Principles and practice of structural equation modeling. Guilford publications. https://books.google.com/books?id=t2CvEAAAQBAJ&lpg=PP1&ots=sWXDS7f0hP&dq=Kline%2C%20R.%20B.%20(2023).%20Principles%20and%20practice%20of%20structural%20equation%20modeling.%20Guilford%20publications.&lr&pg=PP1#v=onepage&q=Kline,%20R.%20B.%20(2023).%20Principles%20and%20practice%20of%20structural%20equation%20modeling.%20Guilford%20publications.&f=false
Kock, N. (2015). Common method bias in PLS-SEM: A full collinearity assessment approach. International Journal of e-Collaboration (ijec), 11(4), 1-10. https://doi.org/10.4018/ijec.2015010101
Köroğlu, E., Köroğlu, R., Sayar, K., Topçuoğlu, V., & Tanrıdağ, T. (2024). The relationship of attachment styles, perceived social support, and anxiety and depressive symptoms with migraine-related disability. Psihologija, 57(3), 307-323. https://doi.org/10.2298/PSI220716010K
Lee, H., Kim, S., & Chang, M. C. (2023). Associations between headache (migraine and tension-type headache) and psychological symptoms (depression and anxiety) in pediatrics: a systematic review and Meta-analysis. Pain Physician, 26(6), E617. https://doi.org/10.36076/ppj.2023.26.E617
López-Solà, M., Suñol, M., & Timmers, I. (2022). Brain predictors of multisite pain onset in children. Pain, 163(4), e502-e503. https://doi.org/10.1097/j.pain.0000000000002430
Neville, A. (2022). Uncertainty Among Youth with Chronic Pain, their Parents, and Clinicians. https://dx.doi.org/10.11575/PRISM/40167
Onofri, A., Ornello, R., Rosignoli, C., Trozzi, V., Adipietro, M. T., Germani, B., D’Ambrosio, M., Cascione, C., Russo, M. E., & Fanì, S. (2025). Headache diagnosis in children and adolescents: validation of the Italian version of the HARDSHIP questionnaire. The Journal of Headache and Pain, 26(1), 169. https://doi.org/10.1186/s10194-025-02113-0
Palermo, T. M., & Chambers, C. T. (2005). Parent and family factors in pediatric chronic pain and disability: an integrative approach. Pain, 119(1-3), 1-4. https://doi.org/10.1016/j.pain.2005.10.027
Paykani, T., Zimet, G. D., Esmaeili, R., Khajedaluee, A. R., & Khajedaluee, M. (2020). Perceived social support and compliance with stay-at-home orders during the COVID-19 outbreak: evidence from Iran. BMC public health, 20(1), 1650. https://doi.org/10.1186/s12889-020-09759-2
Pistoia, F., Salfi, F., Saporito, G., Ornello, R., Frattale, I., D’Aurizio, G., Tempesta, D., Ferrara, M., & Sacco, S. (2022). Behavioral and psychological factors in individuals with migraine without psychiatric comorbidities. The Journal of Headache and Pain, 23(1), 110. https://doi.org/10.1186/s10194-022-01485-x
Rinaudo, C. M., Van de Velde, M., Steyaert, A., & Mouraux, A. (2025). Navigating the biopsychosocial landscape: A systematic review on the association between social support and chronic pain. PLoS One, 20(4), e0321750. https://doi.org/10.1371/journal.pone.0321750
Solé, E., Roman-Juan, J., Sánchez-Rodríguez, E., Castarlenas, E., Jensen, M. P., & Miró, J. (2024). School bullying and peer relationships in children with chronic pain. Pain, 165(5), 1169-1176. https://doi.org/10.1097/j.pain.0000000000003118
Soltani, S., Noel, M., Neville, A., & Birnie, K. A. (2022). Intolerance of uncertainty in pediatric chronic pain: dyadic relationships between youth and parents. The Journal of Pain, 23(9), 1581-1593. https://doi.org/10.1016/j.jpain.2022.04.004
Svetina, D., Rutkowski, L., & Rutkowski, D. (2020). Multiple-group invariance with categorical outcomes using updated guidelines: An illustration using M plus and the lavaan/semtools packages. Structural Equation Modeling: A Multidisciplinary Journal, 27(1), 111-130. https://doi.org/10.1080/10705511.2019.1602776
Taylor, S., Zvolensky, M. J., Cox, B. J., Deacon, B., Heimberg, R. G., Ledley, D. R., Abramowitz, J. S., Holaway, R. M., Sandin, B., & Stewart, S. H. (2007). Robust dimensions of anxiety sensitivity: development and initial validation of the Anxiety Sensitivity Index-3. Psychological assessment, 19(2), 176. https://doi.org/10.1037/1040-3590.19.2.176
Thoits, P. A. (2011). Mechanisms linking social ties and support to physical and mental health. Journal of health and social behavior, 52(2), 145-161. https://doi.org/10.1177/0022146510395592
https://doi.org/10.2307/2136511
Van Buuren, S. (2018). Flexible imputation of missing data. CRC press. https://doi.org/10.1201/9780429492259
Wang, Y. A., & Rhemtulla, M. (2021). Power analysis for parameter estimation in structural equation modeling: A discussion and tutorial. Advances in Methods and Practices in Psychological Science, 4(1), 2515245920918253. https://doi.org/10.1177/2515245920918253
Wildeboer, E. M., Chambers, C. T., Soltani, S., & Noel, M. (2023). The relationship between chronic pain, depression, psychosocial factors, and suicidality in adolescents. The Clinical Journal of Pain, 39(5), 226-235. https://doi.org/10.1097/AJP.0000000000001108
Wolf, M. G., & McNeish, D. (2023). Dynamic: an R package for deriving dynamic fit index cutoffs for factor analysis. Multivariate Behavioral Research, 58(1), 189-194. https://doi.org/10.1080/00273171.2022.2163476
Yang, Y., & Cao, Y. (2023). Rising trends in the burden of migraine and tension-type headache among adolescents and young adults globally, 1990 to 2019. The Journal of Headache and Pain, 24(1), 94. https://doi.org/10.1186/s10194-023-01634-w
Ye, S., Gao, Y., Lin, Y., Wang, J., Wu, I. X., & Xiao, F. (2025). Ambient nitrogen dioxide, temperature exposure, and migraine incidence: A large prospective cohort study. Headache: The Journal of Head and Face Pain, 65(8), 1318-1330. https://doi.org/10.1111/head.15037
Yousefi Afrashteh, M., Abbasi, M., & Abbasi, M. (2023). The relationship between meaning of life, perceived social support, spiritual well-being and pain catastrophizing with quality of life in migraine patients: the mediating role of pain self-efficacy. BMC psychology, 11(1), 17. https://doi.org/10.1186/s40359-023-01053-1
Copyright (c) 2025 International Journal of Body, Mind and Culture
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
