Table of Contents
Primary Category
Headache & Pain
P-Category
Secondary Category
S-Category
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
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
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
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.
Further Reading
- 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
- Kurth T, Diener HC. Migraines and strokes. Journal of the American Heart Association. 20 September 2012; 43:3421–3426. https://doi.org/10.1161/STROKEAHA.112.656603
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.
- 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/
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Written by
ECFMG Certified. Research Associate at NeuroCare.AI Academy
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Written by
Founder NeuroCare.AI, Practicing Neurologist, sub-specialized in the field of Neurocritical Care, Stroke & Epilepsy