Migraine with aura: which patients are most at risk of stroke?

Abstract

The complex association between migraine (M) and ischemic stroke (IS) is discussed. Epidemiological studies and meta-analyses show that M with aura (MA) and not M without aura, doubles the risk of IS. The risk is higher for female gender, young age and higher headache attacks frequency. Smoking habit and oral contraceptives, especially if associated, increase stroke risk. The underlying pathogenetic mechanisms are not completely understood, but it is hypothesized that a particular brain susceptibility to cortical spread depression could explain the association between MA and IS. The absolute risk of IS in migraineurs is relatively low and an antithrombotic primary prevention is not indicated, but it is mandatory to investigate and treat associated risk factors for IS and, in young MA women, consider only progestinic oral contraceptives, if needed, and smoking cessation.

Migraine and Stroke: What’s the Link? What to Do?

“…On the other hand, most studies revealed that migraine without aura does not increase the risk of stroke [11, 23]. Undoubtedly there is a correlation between the frequency of migraine attacks and the risk of stroke [11, 24]. Stroke Prevention in Young Women study revealed a higher stroke risk among women having more than 12 attacks per year [25].…”

Sex‐related influences in migraine

“…Monophasic estrogen/progesterone oral contraceptive pills (OCPs) can be used continuously with rare off‐cycling to prevent spotting, and for many women who have a monthly menstrual migraine, this can effectively eliminate the events (Calhoun and Hutchinson, ). However, migraine with aura (MwA) carries an increased risk of stroke compared with migraine without aura (de Falco and de Falco, ). Older studies with significantly higher doses of estrogen in OCP formulations have correlated MwA and stroke, thus making OCPs an unsafe choice in these patients; however, newer clinical practice is emerging that the current low‐estrogen formulations are prescribed to women with MwA under the assumption that they are nonsmokers and do not have other cardiovascular risk factors (Sacco et al, ).…”

Nonfocal Symptoms in Patients with Transient Ischemic Attack or Ischemic Stroke: Occurrence, Clinical Determinants, and Association with Cardiac History

“…The pathophysiology of stroke in patients with migraine is still unclear. Vulnerability for cerebral ischemia in migraine is possibly caused by cortical hyperexcitability; another hypothesis is that migraine and stroke are triggered by hypoperfusion [11] . Moreover, positive nonfocal symptoms might be epileptic of origin.…”

“…Patients with the use of contraceptives, female gender, or a (family) history of TIA or ischemic stroke more often had migrainelike positive nonfocal symptoms. Female gender and use of contraceptives are risk factors for stroke in patients with migraine [11] . The pathophysiology of stroke in patients with migraine is still unclear.…”