FAMI Questionnaire Shows Positive Results as Tool to Assess Migraine Attack-Related Fear

Factors such as fear of negative consequences, attention and anticipation, and fear-avoidances were identified using the newly developed Fear of Attacks in Migraine Inventory questionnaire, which may have use in clinical settings.

A newly developed self-reported questionnaire, the Fear of Attacks in Migraine Inventory (FAMI), comprising of 29 items, may be suitable as an assessment tool for attack-related fear in persons with migraine, a new study showed. According to the investigators, the questionnaire was easy to apply and has potential in clinical care and research, including diagnostic screening settings as well as a way to evaluate both behavioral and pharmacological interventions for the treatment of migraine.

Using a literature search, interviews with patients with migraine, and discussions with experienced practitioners, the FAMI was originally developed with 46 items. Due to skewness and kurtosis, 4 items were excluded, and due to high interitem correlation, another 12 items were excluded. To understand more about the structure and dimensionality of attack-related fear, investigators sent out a cross-sectional online survey that comprised of an assessment of diagnostic criteria of migraine and a battery of questionnaires including the FAMI.

Led by Timo Klan, PhD, psychotherapist, Johannes Gutenberg Universitat, 7 underlying dimensions of fear of attacks in migraine were assumed in the FAMI, which are as follows:

  • General fear of attacks
  • Performance-related fear of attacks
  • Social aspects of attack anxiety
  • Fear-related medication intake
  • Trigger-related fear of attacks
  • Fear-related avoidance behavior
  • Attentional aspects in fear of attacks

In total, 692 patients started the survey, and after exclusions and incompletions, 387 were included in the final sample. Almost all participants (96.9%) used acute medication, a majority (63.6%) of whom were on a preventative. Most participants were women (94.1%) and chronic migraine was reported by 38.5% of the cohort.

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In the exploratory factor analysis (EFA), 3 clearly interpretable factors were identified. They included fear of negative consequences, attention and anticipation, and fear-avoidance. Among the 3 factors, investigators found 9, 14, and 8 items, respectively, that loaded on each factor. Notably, 2 items—item 5 and item 26—had a double loading. Item 5, "Before important appointments, I worry about the way past migraine attacks interfered with my effectiveness," was allocated to factors 1 and 2 but had a higher loading on the former. Item 26, "After experiencing certain internal states I pay particular attention to signs of an upcoming migraine attack," was allocated to factors 2 and 3 and had a higher loading on the former.

The confirmatory factor analysis (CFA) yielded an acceptable to good model fit (χ2(3) = 1328.84; P = 0.001; χ2/df = 3.55; RMSEA = 0.085; SRMR = 0.073; CFI = 0.98; TLI = 0.97), with factor covariances of 0.72 (factor 1 and 2), 0.60 (factor 1 and 3), and 0.74 (factors 2 and 3).

"Contrary to our expectation, there was no factor related to fear-related medication intake or medication overuse,” Klan et al wrote. "The corresponding items had already been sorted out as part of the item selection process. The only remaining question that refers to 'taking attack medication' (ie, item 17) was factor-analytically assigned to the subscale attention and anticipation. This finding contradicts the assumptions of previous authors who conceptualized the fear of attacks (‘cephalalgiaphobia’) mainly by overuse of acute pain or triptan medication."

On each of the identified factors, McDonalds ω of the factors identified good (fear-avoidance, ω = 0.85; attention and anticipation, ω = 0.88) to excellent (fear of negative consequences, ω = 0.91) reliability. Validity was demonstrated as well, as FAMI sum score and all 3 subscales were significantly positively associated with headache days and days with acute medication during the last month.

The values of the MIDAS, a commonly used migraine questionnaire, were excluded from the analysis because some items of MIDAS did not address all participants and there were incorrect answers by some participants.

"In routine care, the FAMI could be used for the diagnostic screening of attack-related fear in migraine. This would require the determination of a suitable cutoff (e.g., a percentile rank of ≥84 in a representative sample). At least patients with excessive or above-average fear of attacks should be offered a specific behavioral intervention," the study authors wrote. "In addition to decreasing headache activity, interventions for migraine prophylaxis also aim to reduce disability, emotional stress, and anxiety. Because the FAMI expands the armamentarium of migraine-specific measuring instruments it could be used to evaluate both behavioral and pharmacological interventions for the treatment of migraine."

1. Klan T, Brascher AK, Klein S, et al. Assessing attack-related fear in headache disorder–structure and psychometric properties of the Fear of Attacks in Migraine Inventory. Headache. Published February 18, 2022. doi:10.1111/head.14272