Migraine and Stroke. 2023
Migraine is a genetic, inherited condition involving the brain, the trigeminal nerve, and cranial blood vessels which consists of symptoms of episodic headache with intervening periods of normal health.
Twenty-five % of women have migraine at age 42 and six % of men at age 37.
Prevalence of migraine for 100,000 persons
The three most painful human medical conditions are childbirth, kidney stone, and migraine headache. Migraine is the fifth most common disabling medical condition and the tenth most common cause for a visit to the emergency room. For women migraine is their most common chronic medical problem, more prevalent than heart disease, hypertension, diabetes, or arthritis.
Migraine is a painful, disabling condition that strikes more than 1 billion people worldwide and between 38 million and 47 million people in the United States.
The question is does migraine with aura relate to stroke and how does migraine do that?
Severe Migraine Headache
This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, the American Headache Society, migraine textbook author, and blogger.
In general there is an increased risk of stroke for migraine with aura. The risk is highest in women less than 45 years old who smoke cigarettes and are on estrogen based birth control pills.
Since World War II there have been 2 large data centers studying stroke and heart disease. One of them is at the Mayo Clinic in Rochester, Minnesota and the other is in Framingham, Massachusets where the studies are performed at Harvard Medical School. Every doctor has learned to respect Framingham data and Framingham data reveals a 6 % risk of stroke in MA patients.
MA occurs in 30% of the population with migraine. The transitory symptoms of migraine may turn into long lasting neurologic symptoms of a stroke.
Consider my small book on Migraine here.
Related questions
What are the features of Migraine with and without aura Migraine?
Migraine without aura (previously known as common migraine), has attacks that are usually severe, one-sided, throbbing, and associated with nausea, vomiting, or sensitivity to light, sound, or movement. The pain of a migraine is above 5 on a 5-10 scale. Many patients jokingly say to me in my office that their headaches are a “twenty” when asked about a 1-10 scale.
When untreated, these attacks typically last 4-72 hours. A combination of features is required for the diagnosis, but not all features are present in every attack or in every patient.
Migraine with aura (MA), occurs in 30 percent of migraine patients. MA attacks are usually preceded or accompanied by transient focal neurologic symptoms, which are usually visual. Migraine with aura was previously known as classic migraine.
Transient migraine aura visual symptoms may be positive, such as seeing black and white or colored zig-zag shaped images that flash and move or negative such as seeing a blank spot (scotoma) or only half of things.
Since estrogen based birth control pills can increase stroke risk in MA patients, it is important to educate all Migraine persons about this.
Colored migraine image starting at a and moving to C
Non-visual aura symptoms may be numbness spreading from fingers to hand to cheek, or tongue. Sensory symptoms occur in 32% of patients with MA, ICHD 3 allows migraine with aura symptoms to only last less than 60 minutes and when stroke occurs with this condition, the symptoms continue long term.
The difficulty talking is called aphasia and may be blocked speech, or trouble naming things.
The aura symptoms characteristically come 30 minutes before the headache starts, although some persons have the aura in the middle or the end of the headache. At least one aura symptom develops gradually over 5 minutes and/or different aura symptoms occur in succession over 5 minutes. Each symptom lasts 5 or 60 minutes.
In a recent large, population-based study, 64 percent of patients with migraine had only migraine without aura, 18 percent had only migraine with aura, and 13 percent had both types of migraine (the remaining 5% had aura without headache).
Tension Type Headache is usually bilateral, described as “tight or pressure” and may only be mild or moderate. It should be less than 5 on a 1-10 pain scale. Any severe and recurrent headache is most likely to be a form of migraine and to be responsive to anti-migraine therapy.
These symptoms distinguish migraine from tension-type headache, the most common type of headache. Tension Type Headache is 70 % of headache and relates to the anxiety disorders, while migraine is 30 % of headache.
What is Migrainous infarction? Infarction is a medical term indicating dead tissue, like the stroke that occurs in the brain from lack of blood (ischemia) or bleeding into the brain (hemorrhage), A heart attack is called an “MI—myocardial infarction.”
Migraine with aura and stroke is the production of a migrainous infarction.
How does a stroke occur in migraine with aura patients?
Migraine affects blood clotting and platelet aggregation which relates to stroke mechanism . Migraine also accelerates “hardening of the arteries” which means it advance atherosclerosis.
People who have migraines with aura are more likely to have strokes caused by either a blood clot in the heart (cardio-embolic stroke) or a clot within the brain’s blood vessels (thrombotic stroke), compared to those that don’t have migraines with aura, according to research presented at the American Stroke Association’s International Stroke Conference 2016.
Some people with migraines experience neurological symptoms (aura) such as flashes of light, blind spots, or tingling in the hand or face. In adults, symptoms usually happen before the headache itself. Migraines with aura account for less than 20 percent of all migraines, researchers said.
In a 25-year ongoing study of 12,844 adults (age 45-64) in four U.S. communities, 817 participants were identified as having an ischemic strokes (clot or a mass clogs a blood vessel, cutting off the blood flow to brain cells).
When they compared migraine with aura patients to those who had migraine without aura, researchers found:
Overall, migraine with aura patients were 2.4 times more likely to have an ischemic stroke.
Migraine with aura patients were three times more likely to have an ischemic stroke caused by a mass or a clot that forms in the heart, dislodges and travels to the brain (cardio-embolic stroke).
Migraine with aura patients were twice as likely to have an ischemic stroke caused by a clot that develops in a clogged part of the blood vessel supplying blood to the brain (thrombotic stroke).
There was no significant association between migraine with aura and ischemic stroke caused by blockage of small arteries that supply blood to deep brain structures (lacunar stroke).
Since migraines alter the blood vessels in the brain, the greater incidence of strokes caused by blood clots in the heart or the brain’s blood vessels suggests that migraine also affects blood vessels in the heart and neck. That’s what possibly leads to these specific subtypes of stroke, said Souvik Sen, M.D., M.P.H., study author and a neurologist at the University of South Carolina School of Medicine in Columbia, South Carolina.
What kind of strokes occur with migraine with aura?
The usual type of stroke that occurs with migraine without aura is an “ischemic stroke,” as opposed to a hemorrhagic stroke. Ischemia means “lack of blood” either from a closed artery, called a “thrombus” or from a small blood clot, called an, “embolus.”
Thrombosis. An example of a thrombosed artery would be blockage of the left carotid artery in the neck, which leads from the heart to the brain. Then with closure of the left carotid artery, part of the left brain will be deprived of blood and will be ischemic and cause an infarct (dead brain tissue). This would be called a cerebral infarct.
Atherosclerotic artery on right.
Emboli. Emboli are usually formed in the heart in patients who have atrial fibrillation, an irregular heart beat where the top part of the heart, the atrium, doesn’t contract. This allows blood to sludge and form a clot which then drops down into the lower part of the heart, the ventricle. Then the ventricle contracts and shoots the clot into the brain. Severe, large strokes can occur from atrial fibrillation.
Left carotid artery embolic stroke to left brain.
Hemorrhage. Hemorrhagic strokes are rarer with migraine and are usually more severe and deadly than ischemic strokes. Hemorrhage comes when arterial blood at high pressure, being pumped by the heart, is released into the brain through a defect in the arterial wall.
Large left temporal hemorrhagic infarct.
Why does cigarette smoking have an increased risk of stroke for migraine with aura persons? Cigarette smoking is a terrible health risk habit. Nicotine is a very addictive drug and almost as addictive as cocaine. Also, the cigarette smoke and burned ash byproducts produce cancer and lead to an increased risk of the development of atherosclerosis.
Athero means “fat” and sclerosis means “hard.” The American Heart Association has strongly declared that cigarette smoking worsens atherosclerosis and increases the risk of stroke and heart attack. Cigarette smoking is listed as a risk factor for stroke.
Why do estrogen based birth control pills increase the stroke rate for women with migraine with aura? The worst combination of stroke risk factors are a woman with migraine with aura, who is aged less than 45 years old, who takes an estrogen based birth control pill, and who smokes.
Estrogen-based birth control pills.
Estrogen based birth control pills aggravate stroke in MA patients by increasing their blood pressure and making blood hypercoaguable (more likely to clot).
Estrogen based birth control pills also may aggravate or drive migraine attacks, cause abortion, and increase the risk of breast cancer.
Are there other reasons for stroke with migraine with aura? Yes, migraine with aura is also associated with:
Patent foramen ovale
Arterial dissection of cervical arteries
Migrainous infarction
Genetic predisposition
Reports of polymorphism
Endothelial dysfunction
Coagulation abnormalities
Decreased resistance to activated protein C
Protein S deficiency
Antibodyphospholipid antibody syndromes
This is a large group of rare associated conditions which migraine with aura and stroke share. Migrainous infarction is the occurrence of a CAT scan or MRI scan proven acute stroke that occurs during a migraine with aura attack.
Patent foramen ovale is a controversial relationship between migraine with aura and a small hole in the heart left over in some persons from the circulation their heart had with their mother in her womb. It has been studied extensively as to whether surgical closure would be helpful and the result is to not do surgery for this condition.
Rarely migraine with and without aura are associated with a tear in the inside of the carotid artery, a condition called arterial dissection. Dissection can result from unusual neck positions such as turning the head far to one side. It can occur during chiropractic neck manipulation.
What can be done to prevent stroke in persons with migraine with aura? All are called to follow the American Heart Association’s recommended lifestyle:
1.Genetic link to atherosclerosis. All that can be done here is to be aware of familial risk factors for atherosclerosis and work on treating or avoiding them.
2.Exercise aerobically 3-4 days a week for 20-30 minutes. Aerobic exercise increases the heart rate. Good examples of aerobic exercise are jogging, swimming, stationary bicycle, rowing, Jane Fonda type group exercise, and an elliptical machine.
Here we go, get ‘er up 2, 3, 4. Very good 2. 3. 4
3.Treat hypertension.
4.Treat diabetes.
5.Lower cholesterol and lipids.
6.Avoid smoking.
7. Maintain a reasonable weight.
8. And for migraine with aura patients, don’t take estrogen-based birth control pills.
Check out my Big Book on Migraine here.
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All the best.
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Britt Talley Daniel MD