Document Type : Original Article


1 Department of Clinical Psychology, School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran Student Research Committee, Iran University of Medical Sciences, Tehran, Iran Tehran Institute of Psychiatry, Iran University of Medical Sciences, Tehran, Iran

2 Department of Psychology, School of Humanities, Tarbiat Modares University, Tehran, Iran

3 Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran

4 Department of Clinical Psychology, School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran Tehran Institute of Psychiatry, Iran University of Medical Sciences, Tehran, Iran

5 Department of Clinical Psychology, School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Iran University of Medical Sciences, Tehran, Iran


Background: Generalized anxiety disorder (GAD) often remains undiagnosed in patients with migraine, while comorbidity of GAD with migraine is associated with increased dysfunction and risk of chronic migraine. Generalized Anxiety Disorder Scale 7-item (GAD-7) and Generalized Anxiety Disorder Scale 2-item (GAD-2) are the commonly employed screening measures for generalized anxiety symptoms in different patient groups. The present study aimed to evaluate psychometric properties of the Persian version of GAD-7 and GAD-2 in migraine.
Methods: In this cross-sectional study, patients were diagnosed with migraine headaches according to the International Classification of Headache Disorders, 3rd edition (ICHD-3); then they participated in the psychiatric diagnostic interview, and filled out GAD-7, GAD-2, Beck Anxiety Inventory (BAI), Headache Impact Test-6 (HIT-6), and Migraine-Specific Quality of Life Questionnaire version 2.1 (MSQv2.1). The psychometric properties of GAD-7 and GAD-2 were examined using SPSS and LISREL.
Results: Final samples were 186 patients with migraine that 83 patients received a diagnosis of GAD. Confirmatory factor analysis (CFA) indicated that the one-factor model of GAD-7 fit the data well. Internal consistency, test-retest, and Guttman split-half reliability of GAD-7 and GAD-2 were good. Significant correlation results, average variance extracted (AVE), and composite reliability (CR) supported the construct validity of the GAD-7. A score of ≥ 10 in GAD-7 and ≥ 3 in GAD-2 achieved satisfactory sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) (GAD-7: 92%, 90%, 88%, and 93%, respectively; GAD-2: 79%, 88%, 71%, and 91%, respectively).
Conclusion: Our findings supported GAD-7 and GAD-2 for assessing GAD in patients with migraine. It seems that GAD-7 and GAD-2 accurately diagnosed GAD in this group of patients.


  1. The international classification of headache disorders, 3rd edition (beta version). Cephalalgia 2013; 33(9): 629-808.
  2. Hildreth CJ, Lynm C, Glass RM. JAMA patient page. Migraine headache. JAMA 2009; 301(24): 2608.
  3. Global, regional, and national burden of neurological disorders, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2019; 18(5): 459-80.
  4. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017; 390(10100): 1211-59.
  5. Global, regional, and national burden of migraine and tension-type headache, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2018; 17(11): 954-76.
  6. Steiner TJ, Stovner LJ, Vos T, Jensen R, Katsarava Z. Migraine is first cause of disability in under 50s: Will health politicians now take notice? J Headache Pain 2018; 19(1): 17.
  7. Bagley CL, Rendas-Baum R, Maglinte GA, Yang M, Varon SF, Lee J, et al. Validating migraine-specific quality of life questionnaire v2.1 in episodic and chronic migraine. Headache 2012; 52(3): 409-21.
  8. Mosconi P. Health-related quality of life (HRQOL) and migraine. J Headache Pain 2001; 2(Suppl 1): s21-s24.
  9. Buse DC, Reed ML, Fanning KM, Bostic R, Dodick DW, Schwedt TJ, et al. Comorbid and co-occurring conditions in migraine and associated risk of increasing headache pain intensity and headache frequency: Results of the migraine in America symptoms and treatment (MAST) study. J Headache Pain 2020; 21(1): 23.
  10. Dresler T, Caratozzolo S, Guldolf K, Huhn JI, Loiacono C, Niiberg-Pikksoot T, et al. Understanding the nature of psychiatric comorbidity in migraine: A systematic review focused on interactions and treatment implications. J Headache Pain 2019; 20(1): 51.
  11. Seng EK, Seng CD. Understanding migraine and psychiatric comorbidity. Curr Opin Neurol 2016; 29(3): 309-13.
  12. Buse DC, Silberstein SD, Manack AN, Papapetropoulos S, Lipton RB. Psychiatric comorbidities of episodic and chronic migraine. J Neurol 2013; 260(8): 1960-9.
  13. Minen MT, Begasse De Dhaem O, Kroon Van Diest DA, Powers S, Schwedt TJ, Lipton R, et al. Migraine and its psychiatric comorbidities. J Neurol Neurosurg Psychiatry 2016; 87(7): 741-9.
  14. Lipton RB, Fanning KM, Buse DC, Martin VT, Hohaia LB, Adams AM, et al. Migraine progression in subgroups of migraine based on comorbidities: Results of the CaMEO Study. Neurology 2019; 93(24): e2224-e2236.
  15. Goulart AC, Santos IS, Brunoni AR, Nunes MA, Passos VM, Griep RH, et al. Migraine headaches and mood/anxiety disorders in the ELSA Brazil. Headache 2014; 54(8): 1310-9.
  16. Jeyagurunathan A, Abdin E, Vaingankar JA, Chua BY, Shafie S, Chang SHS, et al. Prevalence and comorbidity of migraine headache: Results from the Singapore Mental Health Study 2016. Soc Psychiatry Psychiatr Epidemiol 2020; 55(1): 33-43.
  17. Roy-Byrne PP, Wagner A. Primary care perspectives on generalized anxiety disorder. J Clin Psychiatry 2004; 65(Suppl 13): 20-6.
  18. Wittchen HU, Zhao S, Kessler RC, Eaton WW. DSM-III-R generalized anxiety disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51(5): 355-64.
  19. Maier W, Gansicke M, Freyberger HJ, Linz M, Heun R, Lecrubier Y. Generalized anxiety disorder (ICD-10) in primary care from a cross-cultural perspective: A valid diagnostic entity? Acta Psychiatr Scand 2000; 101(1): 29-36.
  20. Caballero L, Bobes J, Vilardaga I, Rejas J. Clinical prevalence and reason for visit of patients with generalized anxiety disorder seen in the psychiatry out-patient clinics in Spain. Results of the LIGANDO study. Actas Esp Psiquiatr 2009; 37(1): 17-20.
  21. Kujanpaa T, Ylisaukko-Oja T, Jokelainen J, Hirsikangas S, Kanste O, Kyngas H, et al. Prevalence of anxiety disorders among Finnish primary care high utilizers and validation of Finnish translation of GAD-7 and GAD-2 screening tools. Scand J Prim Health Care 2014; 32(2): 78-83.
  22. Kessler RC, Brandenburg N, Lane M, Roy-Byrne P, Stang PD, Stein DJ, et al. Rethinking the duration requirement for generalized anxiety disorder: evidence from the National Comorbidity Survey Replication. Psychol Med 2005; 35(7): 1073-82.
  23. Kessler RC, Keller MB, Wittchen HU. The epidemiology of generalized anxiety disorder. Psychiatr Clin North Am 2001; 24(1): 19-39.
  24. Wittchen HU. Generalized anxiety disorder: prevalence, burden, and cost to society. Depress Anxiety 2002; 16(4): 162-71.
  25. Olfson M, Fireman B, Weissman MM, Leon AC, Sheehan DV, Kathol RG, et al. Mental disorders and disability among patients in a primary care group practice. Am J Psychiatry 1997; 154(12): 1734-40.
  26. Leon AC, Olfson M, Broadhead WE, Barrett JE, Blacklow RS, Keller MB, et al. Prevalence of mental disorders in primary care. Implications for screening. Arch Fam Med 1995; 4(10): 857-61.
  27. Lieb R, Becker E, Altamura C. The epidemiology of generalized anxiety disorder in Europe. Eur Neuropsychopharmacol 2005; 15(4): 445-52.
  28. Judd LL, Kessler RC, Paulus MP, Zeller PV, Wittchen HU, Kunovac JL. Comorbidity as a fundamental feature of generalized anxiety disorders: Results from the National Comorbidity Study (NCS). Acta Psychiatr Scand Suppl 1998; 393: 6-11.
  29. Parmentier H, Garcia-Campayo J, Prieto R. Comprehensive review of generalized anxiety disorder in primary care in Europe. Curr Med Res Opin 2013; 29(4): 355-67.
  30. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Lowe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007; 146(5): 317-25.
  31. Jordan P, Shedden-Mora MC, Lowe B. Psychometric analysis of the Generalized Anxiety Disorder scale (GAD-7) in primary care using modern item response theory. PLoS One 2017; 12(8): e0182162.
  32. Ruscio AM, Chiu WT, Roy-Byrne P, Stang PE, Stein DJ, Wittchen HU, et al. Broadening the definition of generalized anxiety disorder: Effects on prevalence and associations with other disorders in the National Comorbidity Survey Replication. J Anxiety Disord 2007; 21(5): 662-76.
  33. Wittchen HU, Hoyer J. Generalized anxiety disorder: Nature and course. J Clin Psychiatry 2001; 62(Suppl 11): 15-9.
  34. Wittchen HU, Kessler RC, Beesdo K, Krause P, Hofler M, Hoyer J. Generalized anxiety and depression in primary care: Prevalence, recognition, and management. J Clin Psychiatry 2002; 63(Suppl 8): 24-34.
  35. Rapaport MH, Clary C, Fayyad R, Endicott J. Quality-of-life impairment in depressive and anxiety disorders. Am J Psychiatry 2005; 162(6): 1171-8.
  36. Ruiz MA, Zamorano E, Garcia-Campayo J, Pardo A, Freire O, Rejas J. Validity of the GAD-7 scale as an outcome measure of disability in patients with generalized anxiety disorders in primary care. J Affect Disord 2011; 128(3): 277-86.
  37. Stein DJ. Comorbidity in generalized anxiety disorder: impact and implications. J Clin Psychiatry 2001; 62(Suppl 11): 29-34.
  38. The National Institute for Health and Care Excellence (NICE). Generalised anxiety disorder and panic disorder in adults: management [Online]. [cited 2011]; Available from: URL:
  39. First MB. Structured clinical interview for DSM-IV (SCID-I/SCID-II). In: Kreutzer J, Caplan DB, Editors. Encyclopedia of clinical neuropsychology. Hoboken, NJ:  John Wiley & Sons, Inc; 2011.
  40. World Health Organization (WHO). Composite International Diagnostic Interview (CIDI core) Version 2.1 [Online]. [cited 1998]; Available from: URL:
  41. Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006; 166(10): 1092-7.
  42. Toussaint A, Husing P, Gumz A, Wingenfeld K, Harter M, Schramm E, et al. Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7). J Affect Disord 2020; 265: 395-401.
  43. Plummer F, Manea L, Trepel D, McMillan D. Screening for anxiety disorders with the GAD-7 and GAD-2: A systematic review and diagnostic metaanalysis. Gen Hosp Psychiatry 2016; 39: 24-31.
  44. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). Washington, DC: American Psychiatric Publishing; 2013.
  45. Tiirikainen K, Haravuori H, Ranta K, Kaltiala-Heino R, Marttunen M. Psychometric properties of the 7-item Generalized Anxiety Disorder Scale (GAD-7) in a large representative sample of Finnish adolescents. Psychiatry Res 2019; 272: 30-5.
  46. Wild B, Eckl A, Herzog W, Niehoff D, Lechner S, Maatouk I, et al. Assessing generalized anxiety disorder in elderly people using the GAD-7 and GAD-2 scales: Results of a validation study. Am J Geriatr Psychiatry 2014; 22(10): 1029-38.
  47. Garabiles MR, Lao CK, Yip P, Chan EWW, Mordeno I, Hall BJ. Psychometric validation of PHQ-9 and GAD-7 in Filipino migrant domestic workers in Macao (SAR), China. J Pers Assess 2020; 102(6): 833-44.
  48. Bartolo A, Monteiro S, Pereira A. Factor structure and construct validity of the Generalized Anxiety Disorder 7-item (GAD-7) among Portuguese college students. Cad Saude Publica 2017; 33(9): e00212716.
  49. Hinz A, Klein AM, Brahler E, Glaesmer H, Luck T, Riedel-Heller SG, et al. Psychometric evaluation of the Generalized Anxiety Disorder Screener GAD-7, based on a large German general population sample. J Affect Disord 2017; 210: 338-44.
  50. Lowe B, Decker O, Muller S, Brahler E, Schellberg D, Herzog W, et al. Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Med Care 2008; 46(3): 266-74.
  51. Omani-Samani R, Maroufizadeh S, Ghaheri A, Navid B. Generalized Anxiety Disorder-7 (GAD-7) in people with infertility: A reliability and validity study. Middle East Fertil Soc J 2018; 23(4): 446-9.
  52. Micoulaud-Franchi JA, Lagarde S, Barkate G, Dufournet B, Besancon C, Trebuchon-Da FA, et al. Rapid detection of generalized anxiety disorder and major depression in epilepsy: Validation of the GAD-7 as a complementary tool to the NDDI-E in a French sample. Epilepsy Behav 2016; 57(Pt A): 211-6.
  53. Budikayanti A, Larasari A, Malik K, Syeban Z, Indrawati LA, Octaviana F. Screening of generalized anxiety disorder in patients with epilepsy: Using a valid and reliable indonesian version of generalized anxiety disorder-7 (GAD-7). Neurol Res Int 2019; 2019: 5902610.
  54. Delgadillo J, Payne S, Gilbody S, Godfrey C, Gore S, Jessop D, et al. Brief case finding tools for anxiety disorders: Validation of GAD-7 and GAD-2 in addictions treatment. Drug Alcohol Depend 2012; 125(1-2): 37-42.
  55. Esser P, Hartung TJ, Friedrich M, Johansen C, Wittchen HU, Faller H, et al. The Generalized Anxiety Disorder Screener (GAD-7) and the anxiety module of the Hospital and Depression Scale (HADS-A) as screening tools for generalized anxiety disorder among cancer patients. Psychooncology 2018; 27(6): 1509-16.
  56. Baker AM, Holbrook JT, Yohannes AM, Eakin MN, Sugar EA, Henderson RJ, et al. Test Performance Characteristics of the AIR, GAD-7, and HADS-Anxiety Screening Questionnaires for Anxiety in Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2018; 15(8): 926-34.
  57. Seo JG, Park SP. Validation of the generalized anxiety disorder-7 (GAD-7) and GAD-2 in patients with migraine. J Headache Pain 2015; 16: 97.
  58. Simpson W, Glazer M, Michalski N, Steiner M, Frey BN. Comparative efficacy of the generalized anxiety disorder 7-item scale and the Edinburgh Postnatal Depression Scale as screening tools for generalized anxiety disorder in pregnancy and the postpartum period. Can J Psychiatry 2014; 59(8): 434-40.
  59. Zhong QY, Gelaye B, Zaslavsky AM, Fann JR, Rondon MB, Sanchez SE, et al. Diagnostic Validity of the Generalized Anxiety Disorder - 7 (GAD-7) among Pregnant Women. PLoS One 2015; 10(4): e0125096.
  60. Quon BS, Bentham WD, Unutzer J, Chan YF, Goss CH, Aitken ML. Prevalence of symptoms of depression and anxiety in adults with cystic fibrosis based on the PHQ-9 and GAD-7 screening questionnaires. Psychosomatics 2015; 56(4): 345-53.
  61. Teymoori A, Real R, Gorbunova A, Haghish EF, Andelic N, Wilson L, et al. Measurement invariance of assessments of depression (PHQ-9) and anxiety (GAD-7) across sex, strata and linguistic backgrounds in a European-wide sample of patients after Traumatic Brain Injury. J Affect Disord 2020; 262: 278-85.
  62. Doi S, Ito M, Takebayashi Y, Muramatsu K, Horikoshi M. Factorial Validity and Invariance of the 7-Item Generalized Anxiety Disorder Scale (GAD-7) Among Populations with and Without Self-Reported Psychiatric Diagnostic Status. Front Psychol 2018; 9: 1741.
  63. Johnson SU, Ulvenes PG, Oktedalen T, Hoffart A. Psychometric Properties of the General Anxiety Disorder 7-Item (GAD-7) Scale in a Heterogeneous Psychiatric Sample. Front Psychol 2019; 10: 1713.
  64. Rutter LA, Brown TA. Psychometric properties of the generalized anxiety disorder scale-7 (GAD-7) in outpatients with anxiety and mood disorders. J Psychopathol Behav Assess 2017; 39(1): 140-6.
  65. Kertz S, Bigda-Peyton J, Bjorgvinsson T. Validity of the generalized anxiety disorder-7 scale in an acute psychiatric sample. Clin Psychol Psychother 2013; 20(5): 456-64.
  66. Munoz-Navarro R, Cano-Vindel A, Moriana JA, Medrano LA, Ruiz-Rodriguez P, Aguero-Gento L, et al. Screening for generalized anxiety disorder in Spanish primary care centers with the GAD-7. Psychiatry Res 2017; 256: 312-7.
  67. Ahmad S, Hussain S, Shah FS, Akhtar F. Urdu translation and validation of GAD-7: A screening and rating tool for anxiety symptoms in primary health care. J Pak Med Assoc 2017; 67(10): 1536-40.
  68. Ahn JK, Kim Y, Choi KH. The psychometric properties and clinical utility of the Korean version of GAD-7 and GAD-2. Front Psychiatry 2019; 10: 127.
  69. Sousa TV, Viveiros V, Chai MV, Vicente FL, Jesus G, Carnot MJ, et al. Reliability and validity of the Portuguese version of the Generalized Anxiety Disorder (GAD-7) scale. Health Qual Life Outcomes 2015; 13: 50.
  70. Sawaya H, Atoui M, Hamadeh A, Zeinoun P, Nahas Z. Adaptation and initial validation of the Patient Health Questionnaire - 9 (PHQ-9) and the Generalized Anxiety Disorder - 7 Questionnaire (GAD-7) in an Arabic speaking Lebanese psychiatric outpatient sample. Psychiatry Res 2016; 239: 245-52.
  71. Garcia-Campayo J, Zamorano E, Ruiz MA, Pardo A, Perez-Paramo M, Lopez-Gomez V, et al. Cultural adaptation into Spanish of the generalized anxiety disorder-7 (GAD-7) scale as a screening tool. Health Qual Life Outcomes 2010; 8: 8.
  72. Donker T, van Straten A, Marks I, Cuijpers P. Quick and easy self-rating of Generalized Anxiety Disorder: Validity of the Dutch web-based GAD-7, GAD-2 and GAD-SI. Psychiatry Res 2011; 188(1): 58-64.
  73. Belk RA, Pilling M, Rogers KD, Lovell K, Young A. The theoretical and practical determination of clinical cut-offs for the British Sign Language versions of PHQ-9 and GAD-7. BMC Psychiatry 2016; 16(1): 372.
  74. Parkerson HA, Thibodeau MA, Brandt CP, Zvolensky MJ, Asmundson GJ. Cultural-based biases of the GAD-7. J Anxiety Disord 2015; 31: 38-42.
  75. Naeinian MR, Shairi MR, Sharifi M, Hadian M. To study reliability and validity for a brief measure for assessing Generalized Anxiety Disorder (GAD-7). Clinical Psychology & Personality 2011; 3(4): 41-50. [In Persian].
  76. Meyers LS, Gamst G, Guarino AJ. Applied multivariate research design and interpretation. Thousand Oaks, CA: SAGE Publications; 2016.
  77. Masoumian S, Shabani A, Zamirinejad S, Yaghmaeizade H. Psychometric properties of the Structured Clinical Interview for DSM-5, clinician version(SCID-5-CV). Proceedings of the 36th Annual Congress of Iranian Psychiatric Association; 2019 Oct. 15-18; Tehran, Iran. [In Persian].
  78. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: Psychometric properties. J Consult Clin Psychol 1988; 56(6): 893-7.
  79. Hossein Kaviani H, Mousavi AS. Psychometric properties of the Persian version of Beck Anxiety Inventory (BAI). Tehran Univ Med J 2008; 66(2): 136-40. [In Persian].
  80. Kosinski M, Bayliss MS, Bjorner JB, Ware JE Jr, Garber WH, Batenhorst A, et al. A six-item short-form survey for measuring headache impact: the HIT-6. Qual Life Res 2003; 12(8): 963-74.
  81. Zandifar A, Banihashemi M, Haghdoost F, Masjedi SS, Manouchehri N, Asgari F, et al. Reliability and Validity of the Persian HIT-6 Questionnaire in Migraine and Tension-type Headache. Pain Pract 2014; 14(7): 625-31.
  82. Martin BC, Pathak DS, Sharfman MI, Adelman JU, Taylor F, Kwong WJ, et al. Validity and reliability of the migraine-specific quality of life questionnaire (MSQ Version 2.1). Headache 2000; 40(3): 204-15.
  83. Zandifar A, Masjedi SS, Haghdoost F, Asgari F, Manouchehri N, Banihashemi M, et al. The psychometric properties of the Persian migraine-specific quality of life questionnaire version 2.1 in episodic and chronic migraines. ScientificWorldJournal 2013; 2013: 950245.
  84. Netemeyer RG, Bearden WO, Sharma S. Scaling procedures: Issues and applications. Thousand Oaks, CA: SAGE Publications; 2003.
  85. Nunnally JC. Psychometric theory. New York, NY: McGraw-Hill; 1978.
  86. Di Martino S., Di N, I, Esposito C, Prilleltensky I, Arcidiacono C. Measuring subjective well-being from a multidimensional and temporal perspective: Italian adaptation of the I COPPE scale. Health Qual Life Outcomes 2018; 16(1): 88.
  87. Swets JA. Measuring the accuracy of diagnostic systems. Science 1988; 240(4857): 1285-93.
  88. Greiner M, Pfeiffer D, Smith RD. Principles and practical application of the receiver-operating characteristic analysis for diagnostic tests. Prev Vet Med 2000; 45(1-2): 23-41.
  89. Baskin SM, Lipchik GL, Smitherman TA. Mood and anxiety disorders in chronic headache. Headache 2006; 46(Suppl 3): S76-S87.
  90. Lanteri-Minet M, Radat F, Chautard MH, Lucas C. Anxiety and depression associated with migraine: Influence on migraine subjects' disability and quality of life, and acute migraine management. Pain 2005; 118(3): 319-26.
  91. Radat F, Creac'h C, Swendsen JD, Lafittau M, Irachabal S, Dousset V, et al. Psychiatric comorbidity in the evolution from migraine to medication overuse headache. Cephalalgia 2005; 25(7): 519-22.
  92. Beard C, Bjorgvinsson T. Beyond generalized anxiety disorder: Psychometric properties of the GAD-7 in a heterogeneous psychiatric sample. J Anxiety Disord 2014; 28(6): 547-52.
  93. Moreno E, Munoz-Navarro R, Medrano LA, Gonzalez-Blanch C, Ruiz-Rodriguez P, Limonero JT, et al. Factorial invariance of a computerized version of the GAD-7 across various demographic groups and over time in primary care patients. J Affect Disord 2019; 252: 114-21.