What is the significance of migraine with aura as a potential sign of stroke in young patients?

From the Guidelines

Migraine with aura is a significant potential sign of stroke in young patients, particularly in women who smoke and use hormonal contraceptives, with a pooled relative risk of 2.51 (95% CI, 1.52–4.14) compared to those without aura 1.

Key Points to Consider

• Migraine with aura involves temporary neurological symptoms like visual disturbances, sensory changes, or speech difficulties that typically develop gradually over 5-20 minutes and resolve completely within an hour, followed by headache.
• While migraine with aura is associated with a slightly increased risk of stroke, especially in young women who smoke and use hormonal contraceptives, most migraines do not lead to stroke.
• To differentiate between migraine aura and stroke, note that stroke symptoms typically come on suddenly rather than gradually, often affect one side of the body, and don't resolve completely within an hour.
• If a young patient experiences new, severe, or unusual headache symptoms, particularly with neurological deficits that are different from their typical migraine pattern, they should seek immediate medical attention.

Treatment and Prevention

• Treatment for migraine with aura includes acute medications like triptans (sumatriptan, rizatriptan), NSAIDs, and preventive treatments such as anticonvulsants (topiramate), beta-blockers (propranolol), or CGRP antagonists for frequent episodes.
• Young patients with migraine with aura should avoid smoking, consider non-estrogen contraceptives, and manage other cardiovascular risk factors to reduce stroke risk, as advised by the American Heart Association 1.

Important Considerations

• The risk of stroke is higher in women with migraine with aura, especially those under 45 years old, with a relative risk of 3.65 (95% CI, 2.21–6.04) 1.
• The use of oral contraceptives in women with migraine with aura may further increase the risk of stroke, with a relative risk of 7.02 (95% CI, 1.51–32.68) 1.
• It is essential to counsel young patients with migraine with aura on the potential risks and benefits of different contraceptive methods and to encourage them to adopt a healthy lifestyle to reduce their stroke risk.

From the Research

Significance of Migraine with Aura as a Potential Sign of Stroke

• Migraine with aura is associated with an increased risk of ischemic stroke, particularly in young patients 2, 3, 4, 5.
• The risk of stroke is higher in patients with migraine with aura than in those without aura 3, 5.
• Migraine with aura is also associated with an increased risk of cerebral white matter lesions and silent brain infarcts 4, 5.

Risk Factors for Stroke in Patients with Migraine with Aura

• Smoking and oral contraceptive use increase the risk of stroke in patients with migraine with aura 4, 5.
• Classical vascular risk factors, such as hypertension, are more common in patients with migraine 4.
• Atrial fibrillation is a common cause of ischemic stroke in young adults with migraine with aura 6.
• Patent foramen ovale and dissection are also common causes of stroke in patients with migraine with aura 2, 6.

Mechanisms and Pathophysiology

• The exact pathogenesis of migrainous infarct is not known, but it is theorized that cortical spreading depression and vascular factors may play a role 3.
• Endothelial dysfunction and a prothrombotic state may also contribute to the increased risk of stroke in patients with migraine with aura 4.
• The use of vasoconstrictors, such as triptans, may also play a role in the development of stroke in patients with migraine 3.