What are the recommendations for reducing stroke risk in individuals with chronic migraines, particularly those with aura?

Reducing Stroke Risk in Individuals with Chronic Migraines

For individuals with chronic migraines with aura, alternative non-hormonal contraceptive methods should be recommended instead of oral contraceptives to reduce stroke risk, particularly in women under 45 years who smoke. 1

Stroke Risk in Migraine Patients

Migraine with aura significantly increases the risk of both ischemic and hemorrhagic stroke, with specific risk factors that should be addressed:

Risk Stratification

• Migraine with aura: Increases ischemic stroke risk (OR 2.51; 95% CI 1.52-4.14) 1
• Women vs. men: Higher risk in women (OR 2.08; 95% CI 1.13-3.84) than men (OR 1.37; 95% CI 0.89-2.11) 2
• Age: Risk particularly elevated in those under 45 years (OR 3.65; 95% CI 2.21-6.04) 2
• Frequency: Frequent migraine with aura attacks (more than weekly) significantly increase ischemic stroke risk (OR 4.25; 95% CI 1.36-13.29) 2

Compounding Risk Factors

• Smoking: Dramatically increases risk (OR 9.03; 95% CI 4.22-19.34) 2
• Oral contraceptive use: Substantially increases risk (OR 7.02; 95% CI 1.51-32.68) 2
• Combined factors: Women with migraine with aura who smoke and use oral contraceptives have compounded risk 1

Management Recommendations

Contraception Modifications

1. Women with migraine with aura: Should avoid combined hormonal contraceptives due to increased stroke risk 2
2. Alternative contraception: Switch to non-hormonal contraceptive methods 2, 1

Lifestyle Modifications

1. Smoking cessation: Critical for all migraine patients, especially those with aura 2, 1
2. Vascular risk factor management: Identify and modify all vascular risk factors 1

Medication Considerations

1. Triptan use caution: Reasonable to avoid triptans in children with hemiplegic migraine, basilar migraine, known vascular risk factors, or prior cardiac or cerebral ischemia 2
2. Prophylactic options: Consider amitriptyline, sodium valproate (contraindicated in women of childbearing potential), cyproheptadine, or calcium channel antagonists with aspirin if no contraindications 2
3. Beta-blockers: Consider limiting in individuals who developed an infarction while taking prophylactic regimens as they might worsen intracranial vasoconstriction 2

Special Considerations

Women of Childbearing Age

• Women with migraine with aura who are taking oral contraceptives should be counseled to switch to another form of birth control 2
• This recommendation should be considered in the context of overall health implications 2

Monitoring and Follow-up

• Evaluate patients with migraine with aura for other stroke risk factors 2
• Pay special attention to disorders that often feature migraine-like headache such as cervical carotid artery dissection, CADASIL, moyamoya, and MELAS 2
• Monitor attack frequency, as increased frequency in migraine with aura correlates with increased stroke risk 2

Imaging Considerations

• Patients with migraine with aura have an increased risk of infarct-like lesions in the brain (OR 1.4; 95% CI 1.1-1.8), particularly cerebellar lesions in women (OR 1.9; 95% CI 1.4-2.6) 2, 1

Pitfalls and Caveats

• There is currently no evidence that preventive treatment of migraine reduces stroke risk 1
• The absolute risk of stroke remains relatively low in most migraine patients 1
• Migraine without aura does not appear to significantly increase stroke risk 2
• The significance of white matter lesions on MRI in migraine patients remains unclear 1

By addressing modifiable risk factors—particularly smoking cessation and avoiding oral contraceptives in women with migraine with aura—clinicians can help reduce the elevated stroke risk associated with chronic migraines with aura.