Can Migraine Auras Cause Brain Lesions?
Yes, having 5 migraine auras can absolutely result in 4 (or more) brain lesions—the relationship between migraine with aura and brain lesions is well-established, and lesion development does not require a 1:1 correspondence with aura episodes. 1
The Evidence for Migraine-Related Brain Lesions
Women with migraine with aura develop infarct-like brain lesions at significantly elevated rates regardless of attack frequency. 1 The key findings include:
Migraine with aura increases late-life infarct-like lesions by 40% (OR 1.4; 95% CI 1.1-1.8), and this occurs even with infrequent attacks. 2, 1
The CAMERA study demonstrated that migraineurs with aura have a dramatically higher prevalence of subclinical posterior circulation infarcts (OR 13.7; 95% CI 1.7-112). 1
Women with migraine with aura show particular vulnerability to cerebellar lesions (OR 1.9; 95% CI 1.4-2.6). 2, 1
Female migraineurs face independently increased risk of white matter lesions (OR 2.1; 95% CI 1.0-4.1). 1
Why Lesion Count Doesn't Match Aura Count
The relationship between auras and lesions is not linear for several critical reasons:
Multiple lesions can develop from cumulative vascular vulnerability rather than individual aura episodes. 3 In fact, 41.2% of patients with migrainous infarction have multiple lesions simultaneously. 3
Lesions often occur during the interictal phase (between attacks), not just during auras themselves. 4
The mechanism involves chronic vascular changes, hypercoagulable states (OR 6.81; 95% CI 1.01-45.79 in patients <50 years), and endothelial dysfunction that accumulate over time. 1
Cortical spreading depression (the substrate of aura) may directly predispose to brain lesions through mechanisms beyond acute ischemia. 5
Clinical Pattern of Lesions
Lesions predominantly affect the posterior circulation (70.6% of cases), particularly the cerebellum in women. 2, 3 Key characteristics include:
Small lesions are present in 64.7% of cases, and multiple lesions occur in 41.2%. 3
Lesions are located in distinct arterial territories without overlapping patterns, suggesting embolic rather than hemodynamic mechanisms. 3
These are often asymptomatic "silent" infarcts discovered incidentally on MRI. 6
Critical Risk Amplification Factors
If you have migraine with aura and brain lesions, certain factors catastrophically increase stroke risk:
Smoking creates a 9-fold increased stroke risk (RR 9.03; 95% CI 4.22-19.34)—absolute prohibition is mandatory. 2, 1
Estrogen-containing contraceptives increase stroke risk 7-fold (RR 7.02; 95% CI 1.51-32.68)—these are absolutely contraindicated. 2, 1
High migraine frequency (more than weekly) in those with aura amplifies ischemic stroke risk (HR 4.25; 95% CI 1.36-13.29). 2, 7
Age under 45, particularly in women, increases risk (RR 3.65; 95% CI 2.21-6.04). 2, 7
Management Algorithm for Patients with Aura and Lesions
Immediate risk factor elimination:
- Absolutely prohibit tobacco use 1, 7
- Discontinue all estrogen-containing contraceptives 1, 7
- Screen for and aggressively manage hypertension, diabetes, hyperlipidemia 7
- Evaluate for hypercoagulable states and patent foramen ovale (present in 64.7% of migrainous infarction cases) 3
Consider migraine prophylaxis to reduce future lesion accumulation:
- Propranolol 80-160 mg daily or topiramate 50-100 mg daily 1, 7
- While evidence is indirect, reducing aura frequency may decrease lesion burden 1
Antiplatelet therapy consideration:
- Low-dose aspirin for primary stroke prevention remains controversial but reasonable given lesion burden 1
Important Caveats
The absolute risk translates to approximately 4 additional intracranial hemorrhage events per 10,000 women per year with migraine with aura. 2, 7 While relative risks are elevated, absolute risks remain modest for most patients. However, migraine without aura does not carry the same lesion risk—this phenomenon is specific to migraine with aura. 2, 5