Migraine is associated with altered approach–avoidance decision processing: a case control study

BACKGROUND: Behavioral management of migraine has traditionally emphasized trigger avoidance, although emerging evidence supports a shift toward more confrontative coping strategies. Understanding how individuals with migraine process and respond to trigger-related information in approach-avoidance situations is critical for developing targeted interventions. METHODS: Individuals with migraine and migraine-free controls were exposed to visual trigger-related and neutral stimuli prior to making approach-avoidance decisions in an adapted virtual T-maze paradigm. Behavioral measures included decision time (DT) and initial movement response (IMR). Neurophysiological activity was assessed through high-density EEG focusing on frontal alpha asymmetry (FAA), frontal midline theta activity (FMT), and functional connectivity as indexed by the debiased weighted phase lag index (dwPLI). RESULTS: Both groups achieved comparable overall performance. Individuals with migraine exhibited significantly prolonged decision times (DTs), particularly in avoidance and high-conflict conditions, indicating increased cognitive demand. This effect was contrary to the initial hypothesis. Importantly, indirect trigger confrontation did not significantly influence avoidance behavior or decision times, nor did it modulate EEG measures, indicating a robust null effect. As secondary results, neurophysiological analyses revealed reduced FAA and FMT activity as well as situation-dependent alterations in dwPLI-based functional connectivity, providing converging evidence for altered regulatory control and increased neural excitability in migraine. CONCLUSIONS: Migraine is associated with altered approach-avoidance decision processing characterized by increased cognitive demand and impaired regulatory control. Indirect trigger confrontation appears insufficient to systematically modulate these processes within the present paradigm. These findings indicate alterations in decision-making dynamics in migraine. Further research using simpler behavioral paradigms and the utilization of neuromodulation strategies targeting FAA and FMT are required.