Migraine With Aura Linked to Higher Risk of Stroke in Women

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Migraine With Aura Linked to Higher Risk of Stroke in Women

April 28, 2004 (San Francisco) — Women who suffer migraines with aura have a higher likelihood of suffering a stroke, according to research presented here at the American Academy of Neurology annual meeting.

"Overall, headache was not associated with stroke, and migraine was not associated with stroke, but migraine with aura was associated with a 50% increased risk of stroke," lead author Tobias Kurth, MD, an instructor in medicine in the division of preventive medicine at Brigham and Women's Hospital at Harvard Medical School in Boston, Massachusetts, said during a presentation.

The researchers conducted a prospective analysis of almost 40,000 women enrolled in the Women's Health Study, an ongoing prospective cohort study of female health professionals aged 45 years and older.

The researchers relied on the women's self-reporting of migraine, aura symptoms, and headache, but confirmed incidence of stroke with a medical record review.

The researchers analyzed whether there was any association between the reported presence of migraines and headaches and subsequent development of ischemic or hemorrhagic stroke.

During an average of nine years of follow-up, there were 385 confirmed strokes among the women studied, with 309 ischemic, 72 hemorrhagic, and four undefined.

Dr. Kurth reported that women who had migraines with aura had a 50% increased risk of total stroke and a 70% increased risk for ischemic stroke compared with women without migraines. That risk was higher in women younger than 55 years, who had a 70% increased risk of total stroke and more than double the risk of an ischemic stroke.

However, there was no increased risk for women who had nonmigraine headaches, or who had migraine without aura, a subjective sensation often manifesting as a visual disturbance preceding an attack.

There was also no association with any kind of migraine and subsequent hemorrhagic stroke.

The mechanism by which aura might influence ischemic stroke is unclear, but migraine is known to have a vascular component that may cause vessels in the brain to narrow, Dr. Kurth said.

However, he declined to provide any advice for physicians or patients experiencing such migraines with aura. "There is no clinical recommendation," Dr. Kurth said of the findings. "There should not be a real danger for migraineurs with aura, because there is only a small increase in the absolute risk [of stroke]."

However, J. D. Bartleson, MD, associate professor of neurology at the Mayo Clinic in Rochester, Minnesota, and chair of the AAN's practice improvement subcommittee, who was not affiliated with the study, said he might apply the findings to encourage his patients who do suffer migraine with aura to curb other risk factors for stroke, such as smoking or the use of oral contraceptives.

"This confirms what we knew about aura and lessens the concern about the risk of stroke among young women with no aura but frequent migraines," Dr. Bartleson told Medscape. "Now, we would focus on the woman with migraines and aura, although it's still an overall low risk."

The research was funded by the National Institutes of Health.

AAN 56th Annual Meeting: Abstract S24.001. Presented April 27, 2004.

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Cephalalgia. 2006 Aug;26(8):934-9
Prevalence of patent foramen ovale in migraine patients with and without aura compared with stroke patients. A transcranial Doppler study.Carod-Artal FJ, da Silveira Ribeiro L, Braga H, Kummer W, Mesquita HM, Vargas AP.
Department of Neurology, The Sarah Network of Rehabilitation Hospitals, Sarah Hospital, Brazilia DF, Brazil.

The aim of this study was to investigate the prevalence of patent foramen ovale (PFO) in a consecutive unselected cohort of migraine patients (with and without aura) and compare it with a group of ischaemic young and elderly stroke patients. One hundred and forty-one migraine patients were compared with 330 stroke patients (130 young patients; 200 elderly patients) selected from our hospital stroke data bank. PFO was assessed with transcranial Doppler sonography with i.v. injection of agitated saline. The prevalence of PFO was 51.7% in migraine with aura (MA) patients, 33.7% in migraine without aura (MoA) patients, 33.8% in young stroke patients and 20.5% in elderly stroke patients (P < 0.001). The prevalence of PFO in cryptogenic stroke in young and elderly stroke patients was, respectively, 41.1% and 25% (P = 0.04). The difference between MA and MoA patients was significant (odds ratio = 2.1). The prevalence of PFO in MA patients is higher than in MoA patients and in young cryptogenic stroke patients.

PMID: 16886929 [PubMed - indexed for MEDLINE]
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Rev Neurol (Paris). 2007 Jan;163(1):17-25.
[Patent foramen ovale and migraine.][Article in French]
Bousser MG.
Service de Neurologie, Hopital Lariboisiere, Paris.

Recent epidemiological data suggest a bidirectional link between patent foramen ovale (PFO) and migraine with aura (MA) with a relative risk of 2 for PFO in subjects with MA and for MA in subjects with PFO. There is no evidence for a link between PFO and migraine without aura. This link is not systematic and applies only to subsets of PFO, mostly large ones, and to subsets of patients with MA. Although comorbidity cannot be ruled out, it may be that this link is partly causal and that some large PFOs may favor MA attacks in genetically predisposed subjects, by allowing vasoactive substances, platelet emboli or paradoxical emboli to bypass the lung filter and trigger the cortical spreading depression of the aura. The first double blind randomised trial of PFO closure in refractory MA, "MIST", has failed to show a benefit on the primary efficacy end point: cessation of attacks during the analysis period included between 3 and 6 months after the procedure. There is thus at present no scientific reason to look for PFO or to close PFO in migraine patients.

PMID: 17304169 [PubMed - in process]
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Headache. 2007 Feb;47(2):253-65. Links
Influence of MTHFR Genotype on Contingent Negative Variation And MRI Abnormalities in Migraine.de Tommaso M, Difruscolo O, Sardaro M, Losito L, Serpino C, Pietrapertosa A, Santeramo MT, Dicuonzo F, Carella A, Lamberti P, Livrea P.
Background.-The MTHFR C677T genotype has been associated with increased risk of migraine, particularly of migraine with aura (MA) in selected clinical samples and with elevated homocysteine. The hyper-homocysteinemia may favor the vascular and neuronal mechanism underlying migraine, and the risk of stroke. Objective.-The first aim of the present study was to examine the Contingent Negative Variation (CNV) amplitude and habituation pattern in a migraine sample versus non-migraine subjects, at the light of the MTHFR genotype, according to an unrelated and clinical based case-control panel. The second aim was to compare the frequency of Magnetic Resonance Imaging (MRI) subclinical brain lesions across the different C677 genotypes in the same migraine sample, selected for the young age and the absence of any cardiovascular risk factor. Methods.-One hundred and five 18-45 year old out-patients, 90 affected by migraine without aura (MO) and 15 by MA, and 97 non-migraine healthy subjects, age and sex matched, were selected for the genetic analysis. All subjects had a common ethnic origin from Puglia. Sixty-four migraine subjects and 33 control subjects were submitted to the recording of the CNV. All migraine subjects underwent the MRI evaluation. Results.-The frequency of homozygosis was 14.33% in normal subjects, versus 25.7% in MA + MO group (chi(2)-test: 10.80 P= .001). The frequency of homozygosis in MO patients, was 25.5% (MA versus N: chi(2)-test: 9 P= .003), in MA group it was 26.6%. Considering the MTHFR genotype in migraine patients and controls, the C677TT subjects exhibited a reduced habituation index of the early CNV (iCNV), in respect with both C677TC and C677CC; in the migraine group, there was a significant decrease of CNV habituation in patients with homozygosis and a positive correlation between the habituation index values and the homocysteine levels. Nineteen migraine patients exhibited subclinical brain lesions (18.05%): patients with C677T homozygosis did not exhibit a higher risk for MRI abnormalities. Conclusions.-This unrelated and clinical based case-control study showed that genetically induced hyper-homocysteinemia may favor the neuronal factors predisposing to migraine, while it does not influence the presence of subclinical vascular brain lesions probably linked with increased risk of stroke.

PMID: 17300365 [PubMed - in process]
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