Vagally mediated heart rate variability and attachment-related avoidance in pediatric migraine: a mediated pathway to somatic symptoms severity

Highlights: What are the main findings? Attachment-related anxiety and avoidance toward caregivers are associated with severity of somatic symptoms in pediatric migraine. Avoidant attachment toward the father fully mediates the relationship between resting vagally mediated heart rate variability and somatic symptom severity in children and adolescents with migraine. What are the implications of the main findings? Relational factors, especially attachment dynamics, play a central role in understanding somatic distress in pediatric migraine. Targeting both family relationships and physiological regulation may offer added value to current non-pharmacological treatments for pediatric migraine. Background/Objectives: Pediatric migraine is a prevalent and disabling condition often accompanied by functional somatic symptoms and emotional dysregulation. Emerging evidence suggests that autonomic imbalance and insecure attachment patterns may both contribute to the development and maintenance of somatic distress. However, the interplay between physiological regulation and relational dynamics remains insufficiently understood, particularly in pediatric clinical populations. This study investigated whether attachment-related anxiety and avoidance toward both mother and father and resting Vagally Mediated Heart Rate Variability (vmHRV) were associated with somatic symptom severity in adolescents with migraine. Additionally, it tested whether attachment dimensions mediate the association between resting vmHRV and somatic symptoms. Methods: Sixty-one adolescents (aged 11–17 years) with a clinical diagnosis of migraine completed self-report measures assessing somatic symptoms (CSI-24) and attachment dimensions toward each parent (ECR-RC). Resting vmHRV (RMSSD) was recorded during a five-minute baseline. Correlational analyses, multiple regressions, and bootstrapped mediation models were conducted. Results: Higher somatic symptom severity was significantly associated with both attachment anxiety and avoidance toward both parents. Regression models showed that attachment anxiety and avoidance to the mother, along with attachment avoidance to the father, predicted somatic symptoms. Although vmHRV was not directly associated with symptom severity, mediation analysis revealed that attachment avoidance to the father fully mediated the relationship between lower resting vmHRV and increased somatic complaints. Conclusions: These findings highlight the relevance of relational factors in pediatric migraine and suggest that avoidant attachment—particularly toward the father—may serve as a psychological mechanism linking autonomic dysregulation to somatic symptomatology. The results support integrative, biopsychosocial models for understanding and treating primary headache in youth, emphasizing the potential of combining attachment-focused and physiological interventions in clinical practice.