Migraine and Stroke

Migraine is one of the most common neurological disorders affecting 11-15% of the population. About one third of migraineurs have an initial aura of neurological symptoms, most often a visual scotoma (blind spot).

Research has shown an association between migraine with aura and increased stroke risk, although the aetiology of stroke in migraineurs remains unclear. Possible mechanisms of migraine induced stroke include cortical spreading depression, vascular factors, inflammation, endothelial dysfunction, patent foramen ovale, genetics, oral contraceptive pill use and smoking. Patent foramen ovale is controversial, and based on current evidence, closure of PFO is not currently recommended as treatment for migraines.

On imaging, many migraineurs are found to have white matter changes similar to those seen in patients with stroke. White matter hyperintensities (WMH) are a common finding, and are typically multiple, small, punctate hyperintensities in the deep or periventricular white matter often seen in T2 weighted MRI images. The clinical significance of these changes in migraineurs is still unclear.

The mechanism underlying the increased prevalence of WMH in migraine is also not yet well understood. It has been observed however that cerebral blood flow is significantly lower in migraine with aura subjects with high white matter hyperintensity load.

Given the increased risk for stroke in this patient population, it is important to identify and modify any vascular risk factors such as high blood pressure, smoking, combined oral contraceptive use and lifestyle factors.

Available data suggest that the combined hormonal contraceptive may further increase the risk of stroke in those who have migraine, specifically migraine with aura. In women with migraine with aura who are seeking hormonal contraception, it is suggested against prescription of combined hormonal contraceptives, and the use of non-hormonal contraception or progesterone only contraceptives is the preferred option.

References: Zhang, Parikh, Qian, Migraine and stroke. Stroke and Vascular Neurology 2017;2:160-167

Lantz, Sieurin, Sjolander et al. Migraine and risk of stroke: a national population-based twin study. Brain 2017:140;2653-2662

Sacco, Merki-Feld et al. Hormonal contraceptives and risk of ischaemic stroke in women with migraine: a consensus statement from the European Headache Federation (EHF) and European Society of Contraception and Reproductive Health (ESC). The Journal of Headache and Pain 2017:18:108

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