Migraine and ischaemic vascular events

An association between migraine and ischaemic vascular events, particularly ischaemic stroke, has been debated for many years. The pathophysiology of migraine has been explored in detail, and it is known that a dysfunction of brain cells and arteries is a major component of this disorder. The involvement of cerebral arteries during the migraine attack as well as the high prevalence of migraine among young individuals with ischaemic stroke has led to the hypothesis that migraine may be a risk factor for ischaemic stroke. Furthermore, there is evidence that the vascular nature of migraine is not limited to meningeal blood vessels and that migraine and overall cardiovascular disease may share aetiological pathways. The aim of this review is to summarize the epidemiological evidence that links migraine with ischaemic stroke and ischaemic heart disease and to discuss potential biological mechanisms.     

Acute Confusional Migraine May Be a Presenting Feature of CADASIL

Objective.— Characterize the phenomenon of acute confusional migraine (ACM) among Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) patients and emphasize the possibility of CADASIL in adults with ACM.
Background.— ACM, well described in children, has rarely been reported in adults. Although 30-60% of CADASIL patients have migraine, acute confusional state during migraine has not been described. We describe 7 patients with ACM that complicated up to 50% of the migraine episodes.
Design/Methods.— Detailed neurologic evaluation was performed in 20 CADASIL patients; International Classification of Headache Disorders 2nd edition criteria were used to diagnose migraine.
Results.— The mean age was 51 years. Fourteen patients reported headache and 11 met the criteria for migraine (mean age of onset 25). Seven patients experienced concomitant confusion, within 3 years of migraine onset. Confusion occurred either abruptly or insidiously, at the onset of aura or headache, lasting for 2-48 hours, and ending abruptly. These episodes were stereotypic, characterized by disorientation with agitation, and retrograde amnesia for the episodes. Patients reported disorientation to time and place, inability to recognize friends and relatives, difficulty with finding directions home, fear of getting lost, inability to analyze traffic lights or tell time. Patients reliably predicted the episodes and felt the need to seek a safe place for protection. Severity of the episodes progressed, but a striking improvement occurred after the first stroke.
Conclusion.— ACM may be a presenting feature and important clue, enabling CADASIL to be recognized up to a decade or earlier than at present. Therefore, a brain MRI and/or testing for Notch3 mutations should be considered in adult patients with ACM.     

Migraine and Stroke: A Continuum of Association in Adults

Migraine and stroke are the most common neurovascular disorders affecting adults. Migraine, particularly with aura, is associated with increased stroke risk both during and between attacks; as such, migraine may be viewed as a potentially modifiable risk factor for stroke. The exact mechanism by which migraine can predispose to stroke remains uncertain.     

Migraine in the elderly: a review

Although migraine is less prevalent in older than in younger age groups, the absolute increase in the number of subjects in older age groups may lead to an increase in the total number of migraine patients. Consequently, more elderly migraine patients may seek medical attention. In this review, the epidemiology and clinical aspects of migraine in the age group of > or =60 years are summarized, with special attention to comorbidity. The review will focus on treatment choices in elderly migraine patients. These must be based on knowledge of mechanisms of physiological and pathological ageing.     

Migraine, Personality, and Psychiatric Comorbidity

The purpose of this report is to examine the association between migraine and personality, taking into account history of co-occurring psychiatric disorders. Data came from an epidemiologic study of young adults in the Detroit, Michigan metropolitan area. Migraine, defined according to 1988 IHS criteria, and major depression and anxiety disorders were ascertained by a structured diagnostic interview. Migraine was associated with neuroticism, but not with extraversion or psychoticism, measured by the Eysenck's Personality Questionnaire. The association remained significant, when sex and history of major depression and anxiety disorders were controlled. An excess of 25% of persons with migraine alone, uncomplicated by psychiatric comorbidity, scored in the highest quartile of neuroticism. The results suggest that migraine sufferers might be more vulnerable to psychopathology and poor adjustment to their medical condition.     

Migraine Stroke: A Possible Complication of Both Migraine With and Without Aura

We describe four migraine patients who developed an ischemic stroke during their typical migraine attacks.
Cerebral infarction as a possible complication of migraine without aura is discussed.
We propose a review of the migraine stroke definition of the International Headache Society.     

The Shared Genetics of Migraine and Anxious Depression

(Headache 2010;50:1549‐1560) Objectives.— To investigate (1) whether shared genetic factors influence migraine and anxious depression; (2) whether the genetic architecture of migraine depends on anxious depression; (3) whether the association between migraine and anxious depression is causal. Background.— Migraine and anxious depression frequently occur together, but little is known about the mechanisms causing this association. Methods.— A twin study was conducted to model the genetic architecture of migraine and anxious depression and the covariance between them. Anxious depression was also added to the model as a moderator variable to examine whether anxious depression affects the genetic architecture of migraine. Causal models were explored with the co‐twin control method. Results.— Modest but significant phenotypic (rP = 0.28), genetic (rG = 0.30), and nonshared environmental (rE = 0.26) correlations were found between the 2 traits. Interestingly, the heritability of migraine depended on the level of anxious depression: the higher the anxious depression score, the lower the relative contribution of genetic factors to the individual differences in migraine susceptibility. The observed risk patterns in discordant twins are most consistent with a bidirectional causal relationship. Conclusions.— These findings confirm the genetic association between migraine and anxious depression and are consistent with a syndromic association between the 2 traits. This highlights the importance of taking comorbidity into account in genetic studies of migraine, especially in the context of selection for large‐scale genotyping efforts. Genetic studies may be most effective when migraine with and without comorbid anxious depression are treated as separate phenotypes.     

Migraine in Patients With Stroke and Antiphospholipid Antibodies

SYNOPSIS
The association between migraine and antibodies against antiphospholipids is controversial. We investigated the prevalence and the clinical feature of migraine in patients with ischemic stroke and antiphospholipid antibodies. Data were obtained from the medical records of 162 consecutive patients with ischemic stroke over a 2-year period. Ten patients with antiphospholipid antibodies were prospectively identified. A history of migraine was present in 6 of these patients and in only 5 of the 152 patients with negative results for antiphospholipid antibodies (chi-square=47.68; P <.0001). In the former, migraine had been for a long time the only clinical problem before the occurrence of the ischemic stroke. These findings suggest that migraine is frequent and can be an early and a prominent symptom in the antiphospholipid antibodies syndrome. Further studies are needed to fully elucidate the association of migraine and antiphospholipid antibodies. A better knowledge of this association could allow an early identification of patients at high risk of stroke.     

Migraine and stroke in childhood and adolescence

Over 3 years we evaluated two patients, an adolescent and a child, with migraine-like headache and ischemic stroke. Based on our clinical observations and on liter: review of migraine and stroke in the pediatric age group, we believe that the criteria of migrainous infarction outlined by the International Headache Society (IHS) could be occasionally too restrictive Therefore, we suggest subclassifying migrainous infarction into: (i) "definite", referring to the patient: ischemic stroke fulfills all the IHS criteria, (ii) "possible", referring to ischemic strokes which I 1 some, but not all, criteria. This subclassification of migrainous infarction may be relevant in cal practice and in human research studies.     

Migraine and ischaemic heart disease and stroke: potential mechanisms and treatment implications

The migraine-ischemia relationship is best understood in the context of the pathophysiology of migraine. Potential mechanisms of migrainous infarction (stroke occurring during migraine) include vasospasm, hypercoagulability, and vascular changes related to cortical spreading depression. Stroke occurring remote for the migraine attack may be related to arterial dissection, cardioembolism, and endothelial dysfunction. Endothelial dysfunction, a process mediated by oxidative stress, may be a cause or a consequence of migraine, and explain the relationship of migraine to vascular factors and ischemic heart disease. It remains uncertain whether stroke or myocardial infarction can be prevented by migraine prophylaxis, endothelial repair, platelet inhibition, or a combination of these strategies. Although triptans are generally considered safe for use in migraine, caution is warranted in those with multiple vascular risk factors. Known vascular disease is a contraindication to triptan use.     

Allodynia in Migraine: Association With Comorbid Pain Conditions

Background.— Cutaneous allodynia (CA) in migraine is a clinical manifestation of central nervous system sensitization. Several chronic pain syndromes and mood disorders are comorbid with migraine. In this study we examine the relationship of migraine‐associated CA with these comorbid conditions. We also evaluate the association of CA with factors such as demographic profiles, migraine characteristics, and smoking status that may have an influence on the relationships of CA to pain and mood. Methods.— Data are from a cross‐sectional multicenter study of comorbid conditions in persons seeking treatment in headache clinics. Diagnosis of migraine was determined by a physician based on the International Classification of Headache Disorders‐II criteria. Participants completed a self‐administered questionnaire ascertaining sociodemographics, migraine‐associated allodynia, physician‐diagnosed comorbid medical and psychiatric disorders, headache‐related disability, current depression, and anxiety. Results.— A total of 1413 migraineurs (mean age = 42 years, 89% women) from 11 different headache treatment centers completed a survey on the prevalence of comorbid conditions. Aura was reported by 38% and chronic headache by 35% of the participants. Sixty percent of the study population reported at least one migraine‐related allodynic symptom, 10% reported ≥4 symptoms. Symptoms of CA were associated with female gender, body mass index, current smoking, presence of aura, chronic headaches, transformed headaches, severe headache‐related disability, and duration of migraine illness from onset. The prevalence of self‐reported physician diagnosis of comorbid pain conditions (irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia) and psychiatric conditions (current depression and anxiety) was also associated with symptoms of CA. Adjusted ordinal regression indicated a significant association between number of pain conditions and severity of CA (based on symptom count). Adjusting for sociodemographics, migraine characteristics, and current depression and anxiety, the likelihood of reporting symptoms of severe allodynia was much higher in those with 3 or more pain conditions (odds ratio = 3.03, 95% confidence interval: 1.78‐5.17), and 2 pain conditions (odds ratio = 2.67, 95% confidence interval: 1.78‐4.01) when compared with those with no comorbid pain condition. Conclusion.— Symptoms of CA in migraine were associated with current anxiety, depression, and several chronic pain conditions. A graded relationship was observed between number of allodynic symptoms and the number of pain conditions, even after adjusting for confounding factors. This study also presents the novel association of CA symptoms with younger age of migraine onset, and with cigarette smoking, in addition to confirming several previously reported findings.     

Migraine Headache in a Prepaid Health Plan: Ascertainment, Demographics, Physiological, and Behavioral Factors

Background: Migraine is a prevalent disorder whose relationship to other conditions remains poorly understood.
Methods: Associations between migraine and physiological, behavioral, and demographic characteristics were sessed in a retrospective cohort study of 79 588 enrollees in a large prepaid health maintenance organization who underwent a multiphasic preventive health checkup in 1971–1973.
Results: Migraine was found to be inversely associated with age and education and strongly associated with the female sex. The likelihood of migraine was significantly higher among blacks, smokers, those who drink more than six cups of coffee per day, those with Raynaud's syndrome, and those with a family history of migraine. The magnitude of associations between migraine and other factors was, in general, reduced among those with a self-reported physician diagnosis migraine compared to those whose migraine status was defined on the basis of reported symptoms.
Conclusions: Migraine prevalence was found to be higher in blacks and other unspecified minorities than in the white population. The magnitude of the associations between migraine and behavioral risk factors was strongly influenced by the method of migraine ascertainment. The inverse association with level of education suggests that social causation or drift may have been operating in this disease in the early 1970s, 15 to 20 years earlier than recent population-based studies would suggest. Further research is needed to fully appreciate the spectrum of disease and behaviors associated with migraine.     

Migraine and prothrombotic genetic risk factors

It has been suggested that during attacks of migraine both platelet activation and plasma coagulability are increased. We investigated the prevalence of several prothrombotic genetic risk factors in patients with migraine: factor V R/Q 506, factor II 20210 G/A, decanucleotide insertion/deletion in the factor VII promoter, and the platelet HPA-1 and HPA-2 alloantigenic systems, by genotypic identification in an age- and sex-matched case-control study including 106 patients with migraine (49 with aura, and 57 without aura). The prevalence of all genotypes was similar among case patients and controls. No association in relation to the type of migraine was detected in the factor II, factor VII, HPA-1, or HPA-2 polymorphisms. Our results showed a high prevalence of factor V Leiden in those patients with migraine with aura (6.1%), though that association was not statistically significant. The studied prothrombotic genetic factors do not seem to be associated with the development of migraine and, therefore, are not likely relevant in the previously reported hypercoagulability and platelet hyperaggregability in this disease.