Migrainous Infarction

Primary Category

Headache & Pain

P-Category

Secondary Category

S-Category

Authors:

Ashina Khalid Rana MD,
Muhammad Umair MD,
Junaid Kalia MD

Introduction

Defined as a stroke that occurs along with a migraine headache.

Migraines that fit the criteria for migrainous infarction;

The migraine must be associated with an aura; the symptoms of which must last longer than 60 minutes.
The migraine attack must be similar in intensity to the previous migraines.
The symptoms of the aura must correlate to the area of the brain where the stroke has occurred.
Any other medical condition should not be the cause of the stroke

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Migrainous Infarction is Defined as a stroke that occurs along with a migraine headache

Migraines with aura have two-folds increased risk of ischemic stroke

Migrainous infarction accounts for 0.2%-0.5% of all ischemic strokes

Of Note, 18.6% of Stroke have associated headache as presenting symptoms

Epidemiology

Incidence rate ranges from 1.44 to 1.7 per 100,000 persons per year

Individuals with migraines with aura have two-folds increased risk of ischemic stroke

The risk increases with increasing migraine attack frequency.

Women affected more commonly, particularly younger age group.

Visual aura is the most commonly associated feature.

Posterior circulation is more frequently affected.

Migrainous infarction accounts for 0.2%-0.5% of all ischemic strokes.

Pathophysiology

The exact cause of migrainous infarction is still not certain.

Spasm of vertebral or carotid arteries leading to cerebral hypo-perfusion is an important underlying mechanism.

Increased platelets activation during migrainous attack increases the risk of thrombosis.

Platelet activation is enhanced in patients with migraines with aura, even during aura-free and headache-free periods.

Genetic associations between stroke and migrainous infarction

Polymorphism in the MTHFR (methylenetetrahydrofolate reductase) gene.
Angiotensin converting enzyme gene deletion polymorphism (ACE-DD).

Endothelial dysfunction

Reduction in vasodilator activities
Increased endothelial-derived vasoconstriction

Coagulation abnormalities

Increased Platelet-activating factor (PAF)
Increased von Willebrand Factor (vWF)
Decreased resistance to activated protein C
Protein S deficiency

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Precipitating Factors

Overdose of Ergotamine and dihydroergotamine ; can causes constriction of the cerebral vessels.

High dose Oral Contraceptives Pills

Propranolol; permanent neurologic deficits.

Serotonergic Medications; induce ischemic stroke.

Risk Factors

Non-modifiable	Modifiable
Female gender	Hyperlipidemia
Age <45 years	Smoking
History of migraine with aura	Diabetes Mellitus
ㅤ	Oral Contraceptives

Diagnostic Criteria

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Diagnostic Criteria for Migrainous Infarction by International Classification of Headache Disorders (ICHD-3 1.4.3)

The following Criteria needs to be met for diagnosis of

Criteria A

A migraine attack fulfilling criteria B and C

Occurs in a patient with migraines with aura where the aura symptoms persist for more than 60 minutes

Neuroimaging demonstrates ischaemic infarction in a relevant area

Not better accounted for by another ICHD-3 diagnosis.

Of Note: There may be additional symptoms attributable to the infarction

Source: ICH Classfication

Figure 1: Typical manifestation of migrainous infarct

Typical manifestation of migrainous infarct on MRI diffusion weighted in a 45-year-old female patient with chronic migraine with aura.

Differential Diagnosis

Other sources of Ischemic Stroke

Idiopathic thunderclap headache

Arterial dissection

Intracranial neoplasm

Arteriovenous malformation

Treatment and Management

Prevention of stroke in Migraineurs

Risk factor modification

Smoking cessation
Abstinence of Oral Contraceptives

Prophylaxis in Migraineurs at risk for Ischemic CVA

Beta-adrenergic Blocker
Calcium Channel Blocker; Nifedipine
Angiotensin-receptor Blocker
ACE Inhibitors
Statins
Aspirin

Complications

Permanent neurological deficits.

Recurrent episodes of stroke

Bleeding disorder due to medication side effect.

Prognosis

Depends on the timely treatment of migrainous infarction which can prevent permanent neurological deficits.

In majority of the patients that present with prolonged visual auras, and the stroke severity is mild with good short-term and long-term outcomes.

Conclusion

It is imperative to raise more awareness regarding the association of migraine and stroke and the close association between the two.

Further studies are needed to determine more aggressive preventive measures of migraine.

Early identification of risk factors will decrease the risk of migraine associated stroke.

Bibliography

Lee, M. J., Lee, C., & Chung, C. (2016). The migraine–stroke connection. Journal of Stroke, 18(2), 146-156. https://doi.org/10.5853/jos.2015.01683

Wang SJ. Migrainous infarction. MedLink Neurology. Updated 02.28.2021 Released 07.01.1993 EXPIRES FOR CME 02.28.20

Zhang, Y., Parikh, A., & Qian, S. (2017). Migraine and stroke. Stroke and Vascular Neurology, 2(3), 160-167. https://doi.org/10.1136/svn-2017-000077

Kreling GAD, Almeida Neto NR, Santos Neto PJ. Migrainous infarction: a rare and often overlooked diagnosis. Autops Case Rep [Internet].2017;7(2):6168.

https://ichd-3.org/1-migraine/1-4-complications-of-migraine/1-4-3-migrainous-infarction-2/

Lee, M. J., Lee, C., & Chung, C. (2016). The migraine–stroke connection. Journal of Stroke, 18(2), 146-156. https://doi.org/10.5853/jos.2015.01683

Liberopoulos, E. N., & Mikhailidis, D. P. (2006). Could statins be useful in the treatment of patients with migraine? Headache: The Journal of Head and Face Pain, 46(4), 672-675. https://doi.org/10.1111/j.1526-4610.2006.00293.x

Milhaud D, Bogousslavsky J, van Melle G, Liot P. Ischemic stroke and active migraine. Neurology 2001;57:1805-1811.

Ahmadi Aghangar, A., Bazoyar, B., Mortazavi, R., & Jalali, M. (2015). Prevalence of headache at the initial stage of stroke and its relation with site of vascular involvement: A clinical study. Caspian Journal of Internal Medicine, 6(3), 156–160. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4650791/