Stroke and migraine

David Goldemund M.D.
Updated on 06/11/2023, published on 17/02/2023
  • 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 stroke remains 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)
  • Migraine without aura
  • Migraine with aura
    • Migraine with typical aura
      • Typical aura with headache
      • Typical aura without headache
    • Migraine with brainstem aura
    • Hemiplegic migraine
      • Familial hemiplegic migraine (FHM)
        • Familial hemiplegic migraine type 1 (FHM1)
        • Familial hemiplegic migraine type 2 (FHM2)
        • Familial hemiplegic migraine type 3 (FHM3)
        • Familial hemiplegic migraine, other loci
      • Sporadic hemiplegic migraine (SHM)
    • Retinal migraine
  • Chronic migraine
  • Complications of migraine
    • Status migrainosus
    • Persistent aura without infarction
    • Migrainous infarction
    • Migraine aura-triggered seizure
  • Probable migraine
    • Probable migraine without aura
    • Probable migraine with aura
  • Episodic syndromes that may be associated with migraine
    • Recurrent gastrointestinal disturbance
      • Cyclical vomiting syndrome
      • Abdominal migraine
    • Benign paroxysmal vertigo
    • Benign paroxysmal torticollis


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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

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

→ vasoconstriction syndrome


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
  • 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
  • prophylactic migraine therapy does not reduce the risk of stroke [Øie, 2019]


  • favorable in most cases, with complete recovery or only minor residual symptoms

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Stroke and migraine