The present study aimed to outline the socio-cognitive profile of CM + MO. For what concerns socio-cognitive abilities, we had two interesting findings. First, when looking at the differences across socio-cognitive components, a more evident impairment resulted in the affective dimension for CM + MO patients. Second, the HC outperformed both migraine groups, which resulted almost always – with the only exception of the RMET – similar to each other. Such a similitude between CM + MO and EM populations is not surprising if we consider that they represent two different expressions of the same disease. In addition, our EM population had a long history of disease, which was serious enough to push them to seek care in a tertiary referral center. Thus, it is possible that a long exposure to a disabling pain condition may have affected patients’ ability to infer others’ mental states. However, although the two migraine groups were similar in several aspects, a more marked impairment resulted for those with CM + MO with respect to EM in the affective dimension of socio-cognitive abilities. Such results are partially in contrast with Raimo[24] that showed slightly greater difficulties of CM for the cognitive component than the affective one. However, in that study[24], CM patients were compared only with HC, and not with EM as we did. We believe that these affective difficulties should be considered in light of the greater levels of alexythimic and autism traits characterizing CM + MO. Autism research has shown that difficulties in identifying and describing feelings are associated to impairments in recognizing verbal and non-verbal emotional expressions[57–59], and difficulties in experiencing and understanding emotions[60].
Regarding socio-cognitive beliefs, a new topic in migraine research, we found no differences between groups in participants’ perception of how successfully they manage social relationships[61]. Our data for the three groups are in line with the norms of TSIS[48], suggesting that all participants had positive beliefs about their social abilities. If we consider this result in light of the group differences found in the performances, it could be argued that CM + MO patients did not have a clear awareness of their socio-cognitive competencies.
Regarding alexithymia, our results, as found in the literature[14–16], showed an impairment in CM + MO. It corroborates the idea that alexithymia represents a risk factor increasing susceptibility to disease[62]. This is also supported by the differences across groups we found in the autism traits, since it exists a strong association between alexythimic and autism traits, which could be explained by shared characteristics[63, 64]. It is important to consider that these aspects are critical for successful social interactions in everyday life[65]. Interestingly, the CM + MO patients differed significantly from EM and HC individuals in a specific alexithymic facet, which is the difficulty in identifying feelings and distinguishing between feelings and the bodily sensations. Indeed, individuals with high levels of alexithymic traits experience difficulties also for what concerns their non-affective interoceptive state[66]. The inaccurate identification of their bodily sensations[67] could determine a delay in seeking medical treatment[68] and favor substance use disorders[69]. In conclusion, more marked group differences in this alexithymic trait in disfavor of the CM + MO group seems to corroborate previous findings on non-affective interoceptive deficits[66], and may explain MO.
Data regarding social relationships are particularly interesting. On the one hand, we found that the CM + MO group reported higher levels of contact with their family members than the HC did, highlighting chronic patients’ need to maximize the interactions with their relatives. On the other hand, these same patients perceived that they were little supported from the people around them. These findings, although they might seem at odds, actually further highlight patients’ social difficulties. The topic of social relationships in migraine is much debated. There is evidence reporting that migraine patients are less satisfied with social support than the general population[70–72]. Belot[72] found that patients with severe migraine judged the social support they received worse than the general population did. Others[73] reported that poor social support and loneliness in CM were associated with a tendency to MO. Our research group[74] has also shown that both CM and EM patients felt emotionally lonely and less supported than HC after the COVID-19 outbreak. By contrast, it has been shown that headache sufferers had slightly more social support from their families than non-headaches sufferers[75]. Hence, it is difficult to draw definitive conclusions given the heterogeneity of the clinic populations [70–73, 75]. However, our results suggest that CM + MO patients place importance on tangible support from their family members, although they do not feel much satisfied with the support received from social networks[70, 76, 77].
As the importance of socio-cognitive components in defining patients’ profile, we also searched for variables that may predict CM + MO. Patients scored lower in two affective socio-cognitive abilities tests, reported lower prevalence of moderate vs high social support, higher levels of contacts with family members, and lower QoL when compared with HC. It may be that chronic pain has affected social interactions, making patients less adept at inferring others’ mental states. It may also be that long-standing migraine has resulted in less interest in others’ mental and affective states, which in turn may have caused a reduction of social interactions. Both interpretations can be taken as true, in a circular relationship, according to the biopsychosocial model[20].
A similar pattern, albeit less pronounced, was found in the second logistic regression analysis: CM + MO was predicted by lower performances in the ability to infer others’ affective state from looking at the eyes, higher levels of autism traits, and lower QoL than EM. Even if the two migraine groups resulted similar in many socio-cognitive aspects, CM + MO patients were found to be more affected and with lower well-being due to their clinical condition, with negative consequences on understanding others. These factors may act together and predispose the development of this complex clinical condition.
Our study is not without limitations. We did not collect a comprehensive psychopathological assessment. However, we believe that it is important to focus on additional components beside psychopathologies[3–9]. Since this was a cross-sectional study, we are unable to define the causal trajectory involving socio-cognitive components in CM + MO. Finally, the data collection procedure did not reflect the general migraine population, as participants were recruited from a tertiary referral center. Therefore, the transferability of these results to general practice will require confirmation on larger subgroups of patients, in multicenter studies, and with different cultures.