Does Migraine Cause MRI Abnormalities?

Any physician who sees headache patients and reviews MRI scans knows the problem.  The patient has an MRI scan to evaluate some problem—headache, fainting, visual symptoms, off balance.

The radiologist notes numerous T2 microvascular lesions and gives a differential diagnosis of:  autoimmune disease, hypertension, diabetes mellitus, atherosclerotic heart disease, migraine, or demyelinating disease (i.e. multiple sclerosis “MS”).

When the doctor discusses the results with the patient, “MS” is all that the patient hears and focuses on.  If the first doctor is a family practice physician or internist, then the patient is shipped off to a neurologist to sort it out.

The following article is a discussion or whether Migraine can cause MRI abnormalities.

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This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, the American Headache Society, migraine textbook author, podcaster, YouTube video producer, and blogger.

Migraine can cause an increased number of T2 microvascular lesions.  These are referred to casually as “spots or white dots and specifically as WMA’s (White Matter Abnormalities) or T2 microvascular lesions.

As far as is currently known these T2 microvascular lesions are not associated with increased risk of stroke or cognitive loss and have no serious pathological significance.

Related questions:

What is the incidence of these T2 microvascular lesions with migraine?

This is difficult to answer because the studies that have been reported reveal a large variation of incidence  This lack of consistency likely reflects different epidemiologic technique.

Also, reliable medical reports on this issue involve only migraine patients and exclude other medical issues associated with increased numbers of T2 microvascular lesions.

Reported WMA incidence varies from 6%, 10.3%, 12-14%, 16%, 43%, to 12-46%.

What is the incidence of T2 microvascular lesions with various types of Migraine?

The incidence range is:

migraine with aura: 8.1%

migraine without aura: 2.2%

controls: 0.7%

I'd like you to read about Migraine with Aura to be sure that you understand it. Can you believe it, some people still call this "Classical Migraine" a term that went out of date 60 years ago. And the reason I suggest you read this article is sitting several lines up on this page. See it? Migraine with aura has 4 times as many T2 microvascular lesions as migraine without aura. Please read my webpage article on “Migraine with Aura” at doctormigraine.com.

What is the differential diagnosis of T2 microvascular lesions seen on MRI?

Other medical diagnoses that also cause these lesions are:

Diabetes mellitus

Hypertensive and atherosclerotic cardiovascular disease.

Multiple Sclerosis

CADASIL ( Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy)

Stroke

Chronic small vessel deep white matter ischemic change

Autoimmune cerebral vasculitis

How often are patients given a medical diagnosis of  Migraine?

Since the American Migraine Prevalence and Prevention study[i] noted that 56% of patients have ever received a medical diagnosis of migraine, it’s not surprising that the MRI scan shows lesions due to migraine, but the patient has never been given a diagnosis.

In this scenario it is incumbent upon the neurologist to establish a diagnosis, which usually will be migraine with or without aura, and then educate and treat the patient.  The lesions are called “spots, white dots, microvascular T2 lesions, and WMAs (white matter abnormalities).”  The name I like best is “migraine freckles” because it is gently humorous and nearly everybody has freckles.

Help me combat the prevalent ignorance about what migraine is and how to diagnosis it by reading my article "What is Migraine" on my website at doctormigraine.com. Thanks. I feel better now.

What are medical articles on the Frequency of MRI abnormalities with Migraine?

Cooney, et al,[ii] writing in Headache in 1996 on “Frequency of Magnetic Resonance Imaging Abnormalities in Patients With Migraine” noted that MRI abnormalities with migraine had been reported to be “12-46%.”

For their study a neuroradiologist reviewed retrospectively 185 consecutive MRI scans of patients diagnosed with migraine by a neurologist.  They analyzed age, sex, type of migraine, duration of symptoms, and other medical conditions.

Their results were that 16% of the scans had focal white matter abnormalities.  Among patients less than 50 years old and without hypertension, atherosclerotic cardiovascular disease, diabetes mellitus, autoimmune disorder, or demyelinating disease, only 6% had WMAs.

Increased frequency of lesions correlated with age and medical risk factors, but not with sex, type of migraine, or duration of migraine symptoms.  Cooney, et al, stated in conclusion:

“The observed frequency of MRI abnormalities in our series is lower than has been previously reported.  In many cases, these abnormalities may be unrelated to migraine.  When such changes are discovered in a patient with migraine, other etiologies should be considered.”

Swartz, et al,[iii] wrote in 2004 in Archives of Neurology on “Migraine Is Associated With Magnetic Resonance Imaging White Matter Abnormalities.”  They performed a metanalysis of seven studies regarding the relationship between migraine and WMAs.  The authors concluded:

“…subjects with migraine are at higher risk of having WMAs on magnetic resonance images than those without migraine.  This increased risk is present even in younger individuals who do not have co-occurring cerebrovascular disease risk factors.

Prospective studies are needed to determine whether the increased risk of stroke in migraine is mediated or foreshadowed by the presence of WMAs.”

Toth, et al,[iv] writing in 2007 in Ideggyogy Sz on “The prevalence of white matter abnormalities on magnetic resonance images in migraine,” stated:

“The prevalence of WMA was 10.3% among the migraineurs, patients without comorbidities such as hypertension, atherosclerotic heart disease, diabetes mellitus, autoimmune disorder or demyelinating disease and it was 3.1% in the group of controls…without migraine or other disease mentioned above.

The data presented here shows that there is a relationship between migraine and WMA.  The association of WMA and the risk of following stroke is not clear.  There are well known studies analyzing the prevalence of silent infarction too, but there needs to be a long prospective study to answer this question exactly.”

Moschiano, et al,[v] writing in Neurological Sciences in 2007 on “The role of the clinician in interpreting conventional neuroimaging findings in migraine patients” stated:

Changes in cerebral white matter at CT or MRI have been reported in patients with migraine, especially in those with migraine with aura.  Similar pictures may be present in asymptomatic subjects, and their nature is not completely understood, but their infarct-like nature is strongly suggested.

Clinicians play an important role in the evaluation of those migraine patients in whom these nonspecific abnormalities are present.  We suggest ruling out specific syndromes in which migraine attacks are associated with white matter changes, multiple sclerosis and central nervous system vasculitis, as well as evaluating the presence of different vascular risk factors (genetic prothrombotic factors, patent foramen ovale, use of oral contraceptives, etc.)

Their possible causative role in MRI lesions and in enhancing the risk of a negative clinical evolution must be considered in each individual case.

Asma Bashir, et al wrote in Neurology. 2013 Oct 1; 81(14): 1260–1268 on Migraine and structural changes in the brain A systematic review and meta-analysis.

Objective:

To evaluate the association between migraine without aura (MO) and migraine with aura (MA) and 3 types of structural brain abnormalities detected by MRI: white matter abnormalities (WMAs), infarct-like lesions (ILLs), and volumetric changes in gray and white matter (GM, WM) regions.

Methods:

PubMed as well as the reference lists of identified studies and reviews were used to identify potentially eligible studies through January 2013. Candidate studies were reviewed and eligible studies were abstracted. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated for WMAs and ILLs.

Results:

Six population-based and 13 clinic-based studies were identified. The studies suggested that structural brain changes, including WMAs, silent ILLs, and volumetric changes in GM and WM regions, were more common in migraineurs than in control groups. The results were strongest for MA. The meta-analysis of WMAs showed an association for MA (OR 1.68; 95% CI 1.07–2.65; p = 0.03) but not for MO (OR 1.34; 95% CI 0.96–1.87; p = 0.08). The association of ILLs was greater for MA (OR 1.44; 95% CI 1.02–2.03; p = 0.04) than for MO, but no association was found for MA (p = 0.52) and MO (p = 0.08) compared to controls.

Conclusion:

These data suggest that migraine may be a risk factor for structural changes in the brain. Additional longitudinal studies are needed to determine the differential influence of migraine without and with aura, to better characterize the effects of attack frequency, and to assess longitudinal changes in brain structure and function.

Patients who suffer from migraines have reduced cortical thickness and surface area in pain-processing regions of the brain, compared to individuals who never have migraines.

The intensity of a migraine attack can be so severe, people with migraine sometimes question whether their headaches may be causing permanent damage. While there is evidence that brain scans of people with migraine will sometimes detect changes in the form of white matter lesions, a systematic review of migraine and structural changes in the brain from 2013 indicates that these lesions are generally not associated with any neurological issues, and don’t indicate any increased risk of cognitive decline.

American Migraine Trust 2018 document on thoughts on Migraine and Brain Lesions by Dr. Goadsby.

Peter Goadsby, M.B., B.S., a neurologist and professor of neurology at the NIHR Wellcome Trust at King’s Clinical Research Facility in London and the University of California, San Francisco, who led the 2013 study and continues to examine migraine’s lasting neurological effects, says many migraine patients he sees are unnecessarily concerned about long-term brain damage.

“To the best of our understanding, that’s completely wrong,” he says. “There’s no association with cognitive function or thinking problems associated with these changes.”

Overestimating the Implications of Lesions

Goadsby and many other headache specialists say they are confident that the risk of long-term damage is not a cause for concern. Another study they cite to support this is a population-based study from The Netherlands called the CAMERA Study.

In this study, researchers compared the brain scans of healthy control subjects and the scans of people with migraine with aura. They re-examined the same subjects nine years later to determine whether people with migraine developed new lesions and whether these lesions were associated with changes in concentration, memory, information processing, and other cognitive tasks, and found that people with migraine had a slight increase in the number of lesions but that there was no evidence of neurological impairment related to these changes.

These same changes can occur in children and adolescents. In addition, age is a known factor that increases the risk of these tiny white matter lesions. The EVA study, a French population-based study on migraine and cognitive decline, conducted brain scans and cognitive function tests on subjects with and without migraine who were born between 1922 and 1932. Again, they found no correlation between the observed brain changes and any evidence of cognitive dysfunction.

“Sadly, we all get a little bit less cognitively aware, you might say, with time,” Goadsby says. “But there’s no difference between migraine patients and those without migraine. When you look at the population-based evidence, the really good studies, there is no good evidence that those changes in the brain are even lesions, because they don’t cause anything, and there is no evidence at all that migraine does excess damage to the brain.”

Focus On Symptoms, Not Perceived Risks

Dr. Goadsby says patients are often concerned that brain changes correlate with stroke or cognitive dysfunction later in life. This is not the case, and Goadsby says — in fact, the stroke risk for migraine sufferers become less prominent after the age of 45.

“Patients with migraine with aura face a small risk of stroke compared to population controls (healthy individuals without migraine), or patients with migraine without aura,” he says. Because of the low risk, Goadsby says migraine patients who have regular normal physical examinations do not need to get regular brain scans.

He says that the pain of migraine attacks is the symptom that patients and their care teams should prioritize, not the possibility of lesions or the fear of increased stroke risk. It should also be noted that the presence of these “lesions” should not influence the use of any particular medication.

“Migraine is an inherited episodic brain disease,” Goadsby says. “It doesn’t shorten life: it ruins it. Migraine patients do not have to be worried about long-term brain damage. It simply doesn’t happen.”

Mohamed Negm, et al wrote in Egypt J Neurol Psychiatr Neurosurg. 2018; 54(1) on Relation between migraine pattern and white matter hyperintensities in brain magnetic resonance imaging.

Migraine is a common disorder in general population. Presence of white matter hyperintensities (WMHs) in brain MRI of migraine patients was not studied clearly.

Detection of the prevalence of white matter hyperintensities in migraine patients determines its correlation with migraine severity, type and duration.

Methods

Cross sectional analytic study was conducted on migraine patients attending neurology clinic Suez Canal University Hospital. Sixty-five patients with migraine aged from 18 to 50 years were included.

We excluded smokers and patients with hypertension, cardiac disease, diabetes mellitus, endocrine dysfunction, oncological and hematological diseases, infectious diseases, demyelinating disorders, and Alzheimer disease. Brain MRI and laboratory investigation was done for all patients.

Results

White matter hyperintensities were significant more frequent in migraine with aura than those without aura. According to MIGSEV scale, white matter hyperintensities were highly significantly more frequent in grade III severity than grades II and I.

The number of white matter hyperintensities increases significantly with increase intensity of pain during attack. The number of white matter hyperintensities increases significantly with increase intensity of nausea, disability, tolerability during attack and age. Resistance to treatment also shows statistically significant difference in increase number of WMHs.

Conclusions

White matter hyperintensities are present in 43.1% of migraine patients. Age, presence of aura, nausea, disability during attack, resistance to treatment, and severity of headache and duration of migraine are considered a risk factor for development of white matter hyperintensities.

Still educating on what Migraine is, I can't let you get away without reading a very basic, easy to understand article I wrote on "Migraine Headache for Beginners. Please click here.lick this line and read my website article on “Migraine Headache for Beginners.”

Bibliography

[i] Diamond S, Bigal ME, Silberstein S, Loder E, Reed M, Lipton RB.  Patterns of diagnosis and acute and preventive treatment for migraine in the United States:  results from the American Migraine Prevalence and Prevention study.  Headache.  2007;47(3):355-363.

[ii]  Cooney BS, Grossman RI, Farber RE, Goin JE, Galetta SL.  Frequency of Magnetic Resonance Imaging Abnormalities in Patients With Migraine. Headache: The Journal of Head and Face Pain, 1996; 36(10):616–621.

[iii] Swartz RH, Kern RZ.  Migraine Is Associated With Magnetic Resonance Imaging White Matter Abnormalities.  Arch Neurol.  2004;61:1366-1368.

[iv] Toth M, Kundra O, Kulin A.  The prevalence of white matter abnormalities on magnetic resonance images in migraine.  Ideggyogy Sz.  2007;60(5-6):239-244.

[v] Moschiano F, D’Amico D, Di Stefano M, Rocca N, Bussone G.  The role of the clinician in interpreting conventional neuroimaging findings in migraine patients.  Neurol Sci.  2007;28(Suppl 2):S114-117.

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All the best.

Britt Talley Daniel MD