Seby John, MD

Monteith T, Gardener H, Rundek T, Dong C, Yoshita M, Elkind MSV, et al. Migraine, White Matter Hyperintensities, and Subclinical Brain Infarction in a Diverse Community: The Northern Manhattan Study. Stroke. 2014

In this report, Monteith and colleagues studied the link between migraine and subclinical strokes among subjects of the Northern Manhattan Study with a self-reported history of migraine.  Subclinical brain infarction (SBI) and white matter hyperintensity volumes (WMHV) were quantified from the MRI sub-study. 546 subjects had both migraine and MRI data. The authors found that subjects who reported migraine had double the odds of having SBI after adjusting for vascular risk factors, compared to those who didn’t report migraine. There was no association between migraine and WMHV. Other interesting results included a significant association of SBI in patients with migraine without aura, and in older individuals.

The observation of migraine and stroke has been around for many years, even back to the 19th century when Charcot described a case of “complicated migraine”. We now have accumulating evidence that migraine with aura is a risk factor for ischemic stroke, especially in younger individuals. The spectrum of association between these two common neurovascular problems seems to be a continuum ranging from migraine-induced stroke to migraine-related stroke. Multiple pathophysiological mechanisms have been suggested. While intense vasoconstriction may produce migrainous infarction; endothelial dysfunction causing a vasculopathy, unfavorable vascular risk factor profile, increased frequency of PFO’s or use of ergots/triptans in migraineurs may explain stroke occurring temporally remote from a migraine attack.
Women are 4 times more likely to have migraines than men.  The association between migraine aura and ischemic stroke is higher in women, and the risk further increases with OCPs and cigarette smoking. The 2014 guidelines for prevention of stroke in women recommend that treatment to reduce migraine frequency is reasonable, and strongly recommend smoking cessation in women with migraine with aura. Although the absolute risk of migraine-associated stroke is relatively low, little was known about SBI. This raises the question whether more aggressive risk factor modification should be pursued in migraineurs with SBI.