ISCHEMIC STROKE / CLASSIFICATION AND ETIOPATOGENESIS
Stroke and migraine
Created 17/02/2023, last revision 03/09/2023
- migraine is the most common neurological disorder, affecting 10-15% of the adult population
- there is increasing evidence of an association between migraine and vascular disease (ischemic stroke, subclinical brain lesions, cardiac events, and vascular mortality) [Lee, 2016] [Anderson, 2013] [Stang, 2005]
- population-based studies have revealed that patients with migraine with aura have a 2-fold increased risk of ischemic stroke. However, these infarcts are often not migrainous and the mechanisms underlying the increased risk of ischemic stroke in migraineurs remain unclear
- the risk of stroke increases with the frequency of migraine attacks
- most studies have shown no association between migraine without aura and ischemic stroke
- the risk of stroke is increased in young women (< 45 years) with migraine with aura (or with a history of status migrainosus), along with smoking and oral contraceptive use [Millhaud,2001]
- in men, the association between migraine and stroker emains controversial
- despite the high prevalence of migraine, the absolute risk of stroke is low, and migrainous stroke is very rare
- some complicated migraines can be difficult to distinguish from a stroke (stroke mimics)
Etiopatogenesis
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Migrainous infarction
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Migraine and silent strokes
- population-based evidence suggests that some patients with migraine (with and without aura) have an increased risk of subclinical lesions in certain brain areas [Kruit, 2004]
Migraine and TGA
- a higher predisposition to transient global amnesia (TGA) has been reported
Differential diagnosis
- criteria for migraine with aura are met
- one of the aura symptoms lasts > 1 week and imaging studies exclude stroke in the corresponding territory
- Stroke-like Migraine Attacks after Radiation Therapy (SMART) [Black, 2006]
- late sequelae of radiotherapy (separated by several years)
- headache (sometimes with aura) with prolonged but reversible neurological deficits (lasting up to several weeks)
- MRI shows diffuse meningeal enhancement, that resolves spontaneously
- headache + focal neurological deficits + CSF pleocytosis [Cifelli, 2011]
- pleocytosis (> 100)
- protein elevation
- no evidence of OCB or other CSF abnormality
- fever is sometimes present
- usually affects young males
- appropriate investigations must exclude neuroinfection
- MRI and angiography are normal
- the condition usually lasts 6-12 weeks and resolves spontaneously
- triptans may be one of the provoking factors [Kato, 2016]
Management
Primary prevention
- antithrombotics and statins are not necessary for primary stroke prevention (unless indicated for other reasons)
- risk factor modification is suggested (smoking cessation, abstinence from oral contraceptives, proper blood pressure control)
- some drugs used for migraine prophylaxis may also be beneficial in reducing vascular risk
Acute stroke therapy
- standard recanalization therapy in eligible acute stroke patients
Secondary stroke prevention
- antiplatelet therapy
- choose aspirin or clopidogrel
- cilostazol and dipyridamole may provoke migraine-like attacks in migraineurs
- statins may have a prophylactic effect on migraine → see here
- statins reduce the expression of CGRP and substance P and attenuate NF-κB activation in the caudal trigeminal nucleus
- statins reduce the expression of CGRP and substance P and attenuate NF-κB activation in the caudal trigeminal nucleus
- most antihypertensive drugs have some prophylactic effect on migraine [Lee, 2016]
- beta-adrenergic blockers, calcium channel blockers, some angiotensin receptor blockers, and angiotensin-converting-enzyme inhibitors
- there is a theoretical risk of triptans and CGRP antagonists in patients with previous stroke (via vasoconstriction) [Aradi, 2019]
- however, according to AHA/ASA 2021, no clear recommendation can be made due to a lack of data
- population-based studies show no evidence that triptans lead to an increased risk of vascular events
- it is unclear whether the increased risk of stroke is related to therapy or migraine severity
- stroke rarely occurs in migraineurs who do not abuse ergots or triptans
- however, according to AHA/ASA 2021, no clear recommendation can be made due to a lack of data
- prophylactic migraine therapy does not reduce the risk of stroke [Øie, 2019]
Prognosis
- favorable in most cases, with complete recovery or only minor residual symptoms