Can frequent or severe migraine headaches cause nonspecific white matter hyperintensities (WMH) without associated headache symptoms?

From the Guidelines

Yes, it is possible to have migraine-related white matter hyperintensities (WMHs) without experiencing headaches, a condition known as "silent" or "acephalgic" migraine. These brain changes can occur in people who have migraine disease but don't always experience the typical headache symptoms. Migraine is a neurological disorder that affects the brain beyond just causing pain, and some people may have migraine activity in their brain that causes white matter changes visible on MRI scans without triggering headache symptoms. This phenomenon is more common in older adults who may have had migraines earlier in life but now experience different or no symptoms. Other migraine symptoms like visual disturbances, sensory changes, or dizziness might still occur without headache. However, it's essential to note that nonspecific white matter hyperintensities can have many other causes, including aging, high blood pressure, diabetes, or other neurological conditions, as reported in the study by Meschia et al. 1. If WMHs are found on an MRI, a thorough neurological evaluation is necessary to determine the cause, as treatment approaches would differ based on the underlying condition. Some studies suggest that migraine with aura is associated with an increased risk of ischemic stroke and white matter lesions, particularly in women, as seen in the WHS study 1. In contrast, the study by Meschia et al. 1 found that migraine without aura was not associated with an increased risk of ischemic stroke or white matter lesions. The exact mechanism of migraine-related WMHs is still unclear, but it is thought to involve a complex interaction of several converging pathogenic factors, including disturbance of cortical excitability, cortical spreading depression, meningeal inflammation, and activation of the trigeminovascular system, as discussed in the study by Meschia et al. 1. In terms of management, preventive medications such as topiramate, onabotulinumtoxinA, and CGRP monoclonal antibodies may be effective in reducing the frequency and severity of migraine symptoms, including WMHs, as reported in the study by 1. However, more research is needed to fully understand the relationship between migraine and WMHs, and to develop effective prevention and treatment strategies. Key points to consider include:

• Migraine can cause white matter changes in the brain without triggering headache symptoms
• Nonspecific white matter hyperintensities can have many other causes, including aging, high blood pressure, diabetes, or other neurological conditions
• Migraine with aura is associated with an increased risk of ischemic stroke and white matter lesions, particularly in women
• Preventive medications such as topiramate, onabotulinumtoxinA, and CGRP monoclonal antibodies may be effective in reducing the frequency and severity of migraine symptoms, including WMHs.

From the Research

Migraine Headaches and White Matter Hyperintensities

• The relationship between migraine headaches and white matter hyperintensities (WMH) has been studied in various research papers 2, 3, 4, 5.
• Studies have shown that individuals with migraine are more likely to have WMH, which are lesions that appear as bright spots on MRI scans 4, 5.
• The prevalence of WMH in different types of migraine is similar, ranging from 38.7 to 44.4%, and is not limited to specific subtypes of migraine 5.
• WMH are more common in individuals with migraine than in those without, and are associated with an increased odds of having a WMH score ≥3 4.

Asymptomatic Migraine and White Matter Hyperintensities

• There is no direct evidence to suggest that asymptomatic migraine (i.e., migraine without headaches) can cause WMH 2, 3, 4, 5, 6.
• However, it is possible that individuals with migraine may experience WMH without experiencing headaches, as the relationship between migraine and WMH is not fully understood 4, 5.
• Further research is needed to determine the relationship between asymptomatic migraine and WMH, as well as the underlying mechanisms that contribute to the development of WMH in individuals with migraine 2, 3, 4, 5, 6.

Clinical Implications

• The presence of WMH in individuals with migraine may have implications for diagnosis and treatment, particularly in cases where migraine is suspected but not diagnosed 6.
• Clinicians should be aware of the potential for rare causes of migraine, including uncommon neurological diseases that may present with atypical characteristics or prolonged duration 6.
• Early diagnosis and treatment of underlying conditions are crucial for improving patient outcomes, and further research is needed to understand the relationship between migraine and WMH 2, 3, 4, 5, 6.