Blood Pressure During Migraine Episodes
Blood pressure does not consistently increase during migraine attacks; in fact, diastolic hypotension is more commonly observed during migraine episodes in normotensive patients, though the relationship between migraine and blood pressure remains complex and bidirectional.
Blood Pressure Changes During Acute Migraine Attacks
The most direct evidence examining blood pressure during migraine attacks comes from a prospective study of 62 normotensive migraine patients who measured their blood pressure before, during peak headache, and after attacks 1. This study found no statistically significant changes in systolic or diastolic blood pressure across the three time points during migraine attacks 1. However, diastolic hypotension was detected in a considerable number of measurements (5.1% of all measurements), suggesting that if anything, blood pressure tends to decrease rather than increase during attacks 1.
The Migraine-Hypertension Relationship
Cross-Sectional Evidence
The relationship between migraine and chronic hypertension is inconsistent across studies 2. When individual blood pressure parameters are examined:
- Migraine is associated with higher diastolic blood pressures and perhaps lower pulse pressures 2
- Associations with systolic blood pressure are incongruent across studies 2
- When studies of elderly patients are excluded, more studies report positive associations between migraine and high diastolic blood pressure than inverse or neutral associations 2
Longitudinal Evidence
Migraine patients are at increased risk of developing hypertension over time, suggesting migraine may predict future hypertension 2. However, whether pre-existing hypertension predicts new-onset migraine remains inconclusive 2.
Clinical Implications for Blood Pressure Management
Monitoring Recommendations
Clinicians should regularly monitor blood pressure in older patients with migraine who use triptans, in addition to periodic assessment of cardiovascular risk factors 3. This recommendation exists not because blood pressure increases during attacks, but because:
- Triptans have vasoconstrictive properties and should not be used in patients with uncontrolled hypertension 3
- Poor control of blood pressure may exacerbate migraine frequency and severity 4
- Hypertension may induce migraine chronification by amplifying vascular wall effects and enhancing endothelial dysfunction 5
Treatment Considerations
Recent emergency department data provides important practical guidance: Among patients presenting with migraine and elevated blood pressure, 73.2% experienced improvement in diastolic blood pressure and 78.4% improved systolic blood pressure within one hour of receiving headache medication alone 6. This improvement was particularly notable in patients with acutely elevated blood pressure but without diagnosed hypertension, where pain score reduction was associated with blood pressure reduction 6.
This suggests that in most patients with migraine and acutely elevated blood pressure, treating the headache itself may be sufficient to normalize blood pressure without requiring separate antihypertensive medication 6.
Common Pitfalls to Avoid
Do not assume elevated blood pressure during a migraine attack requires immediate antihypertensive treatment 6. Treat the migraine first and reassess blood pressure after headache relief.
Do not use triptans in patients with uncontrolled hypertension or basilar/hemiplegic migraine 3. However, no robust evidence supports increased cardiovascular events from triptan use in older people with controlled hypertension 3.
Be aware that some antihypertensive medications can cause headache, while some migraine medications can exacerbate hypertension, requiring careful therapeutic selection 4.
Consider that monitoring blood pressure is recommended in migraineurs showing an otherwise unexplained increase in attack frequency, as this may indicate developing hypertension contributing to migraine chronification 5.