Can migraines cause stroke-like symptoms?

From the Guidelines

Yes, migraines can cause stroke-like symptoms, particularly in cases of complex migraines such as hemiplegic migraines or migraines with aura. These symptoms may include temporary weakness on one side of the body, numbness, tingling, speech difficulties, vision changes, and confusion. This phenomenon occurs because during certain types of migraines, blood vessels in the brain constrict and reduce blood flow to specific brain regions, temporarily mimicking stroke symptoms. The key difference is that migraine symptoms typically develop gradually over minutes, may shift or spread, and resolve completely within 24 hours, while true stroke symptoms appear suddenly and may cause permanent damage.

Key Considerations

• Migraine with aura seems to increase the risk of ischemic stroke among young individuals, particularly those of childbearing age and those taking oral contraceptives 1.
• A meta-analysis reported an overall pooled RR of 2.04 (95% CI, 1.72–2.43) for the association between migraine and ischemic stroke, with a greater risk in migraine with aura (pooled adjusted OR for 7 studies, 2.51; 95% CI, 1.52–4.14) compared with migraine without aura 1.
• The 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack suggests that practitioners may consider implementing preventive treatments to reduce migraine frequency in patients with migraine and prior ischemic stroke 1.

Recommendations

• If someone experiences stroke-like symptoms for the first time, they should seek immediate medical attention to rule out an actual stroke, as proper diagnosis requires medical evaluation.
• Treatment for migraines with stroke-like symptoms often includes standard migraine medications such as triptans (though these are sometimes avoided in hemiplegic migraine), anti-inflammatory medications, anti-nausea drugs, and preventive medications like topiramate, propranolol, or newer CGRP inhibitors if migraines are frequent.
• Keeping a symptom diary can help identify triggers and distinguish these episodes from more serious conditions.
• Avoiding oral contraceptive agents with exogenous estrogen in women with migraine with aura and prior ischemic stroke may be appropriate, given the increased risk of stroke associated with their use 1.

From the FDA Drug Label

Cerebral hemorrhage, subarachnoid hemorrhage, and stroke have occurred in patients treated with 5-HT1 agonists, and some have resulted in fatalities In a number of cases, it appears possible that the cerebrovascular events were primary, the 5-HT1 agonist having been administered in the incorrect belief that the symptoms experienced were a consequence of migraine when they were not. Also, patients with migraine may be at increased risk of certain cerebrovascular events (e.g., stroke, hemorrhage, TIA).

Migraines may be associated with an increased risk of cerebrovascular events, including stroke. However, it is not clear if migraines can directly cause stroke-like symptoms. The FDA drug label suggests that patients with migraine may be at increased risk of certain cerebrovascular events, but it does not provide direct evidence that migraines can cause stroke-like symptoms 2.

From the Research

Migraine and Stroke-Like Symptoms

• Migraines can cause stroke-like symptoms, making diagnosis challenging 3, 4, 5, 6, 7.
• Studies have shown that migraine with aura can be a stroke mimic, accounting for 1.79% of all emergency stroke unit evaluations and 12.24% of stroke mimics not treated with systemic thrombolysis 7.
• Migraine aura-like symptoms at the onset of stroke and stroke-like symptoms in migraine with aura are common, with 22.3% of stroke patients reporting visual symptoms and 41.4% reporting sensory symptoms 4.

Diagnostic Challenges

• Differentiating between migraine aura and transient ischemic attacks remains challenging due to overlapping symptoms 3, 4.
• Failure to identify cerebral ischemia among patients with headache and overdiagnosis of ischemia can lead to patient harm 3.
• Clinical prediction scores with high sensitivity and specificity exist to aid in the diagnosis of acute cerebral ischemia, but additional strategies are needed to improve diagnostic safety among patients with migraine and/or cerebral ischemia 3.

Migrainous Infarction

• Migrainous infarction is a rare but specific type of ischemic stroke that develops during an attack of migraine with aura 6.
• Migraine with aura is a risk factor for ischemic stroke in women under 45 years, particularly when combined with other risk factors such as smoking and oral contraceptives 6.
• Individuals with migraine with aura seem to have more white matter lesions and ischemic infarctions than control patients, highlighting the need for careful management and potential prevention strategies 6.