Your competent? doctor knew of this risk years ago and DELIVERED EXACT PROTOCOLS TO FIX THE PROBLEM, RIGHT? Sorry, nothing occurred! Well when you have a board of directors so fucking incompetent they can't see what incompetence looks like in staff, then you get crapola like this!
- migraine
(47 posts to February 2011)
Migraine and Stroke: What's the Real Risk?
This transcript has been edited for clarity.
Indira Subramanian, MD: Hi. Welcome, everyone, to Medscape. I'm so excited to have Professor Andrew Charles here, from UCLA, who's a professor of neurology there and the director of the Goldberg Migraine Program. He is a good friend and colleague, and he was also my residency program director back in the day.
My name is Indu Subramanian. I'm a neurologist here at UCLA. Today, we're going to be debunking myths in migraine. Welcome, Andy.
- Migrainous infarction during aura is very rare.
- Migraine w/ aura linked to ↑ stroke risk in select patients.
- Risk may relate to right-to-left shunt, esp PFO.
- PFO present in ~25%; big shunts may raise migraine + stroke risk.
- Triptan vascular complications uncommon; labels still list CV/CVA contraindications.
Andrew C. Charles, MD: Thanks very much. Great to be with you, Indu.
Migraine, Ischemia, and Stroke
Subramanian: I think one of the worries about migraine is about ischemia and causing stroke or the risk for strokes in migraine patients. Maybe we could talk a little bit about that.
Charles: Yeah, this idea comes from the vascular hypothesis of migraine, that migraine is this phenomenon where there's constriction and dilation of blood vessels. One of the myths is that, especially in migraine with aura, that migrainous infarction occurs. Basically, what that term means is that the stroke happens during a migraine attack related to something going on with the blood vessels during the migraine attack.
It turns out that migrainous infarction is really very rare. Still, there is this increased risk for stroke in certain populations of individuals, particularly with migraine with aura. Interestingly, this is not necessarily in people who have other stroke risk factors, so it may be people who have a clean vascular bill of health, but otherwise then have this unexpected risk associated with aura. That's led to certain organizations like the World Health Organization or even ob/gyn organizations to say that women with migraine with aura should not take estrogen-based oral contraceptives.
I will say, just right off the bat, that most neurologists, and most headache neurologists, specifically, think that is incorrect. The reason that's incorrect is that most of the studies that were done regarding oral contraceptives in women with stroke were using very high-dose estrogen, which is associated with stroke regardless, and in particular in the setting of migraine. That's where the stroke risk was seen.
There's been an interesting shift in our thinking about this away from the idea that it's migrainous infarction, especially during the aura, but rather that maybe there's something that's associated with migraine with aura that's also associated with stroke.
That is a right-to-left shunt, meaning any kind of shunt that allows blood from the right side of the circulation to travel directly to the left. The most common cause of that seen in practice is a patent foramen ovale (PFO), which is present in about 25% of people. We think in certain individuals, especially those with big PFOs, that's number one, a risk factor for migraine, but it's also independently a risk factor for stroke.
One of the ways that's changed our clinical practice is if we have patients with very frequent aura, and particularly aura that's more than just visual aura, we'll often do a transcranial Doppler study with agitated saline to look for a right-to-left shunt. Then the question is: What do you do about it if you find it?
For some individuals, even though the studies have not hit clinical endpoints in terms of benefit for migraine, we do see people having really dramatic benefit in some cases in terms of migraine frequency, but we're also thinking about it in terms of reducing stroke risk. It pulls in the stroke side of things when we see these patients where we're not just thinking about trying to reduce their migraine, but also can we treat it in a way that will reduce potential stroke risk.
Subramanian: Are there any contraindications for using abortives in terms of vascular issues?
Charles: If you read the labels, triptans, for example, are still contraindicated in patients with either cardiovascular disease or cerebrovascular disease. However, our experience over now decades of use is that vascular complications are in fact very unusual.
Going back to the magnetic resonance angiography (MRA) studies, showing that, in fact, if you give triptans during a migraine attack, it does not constrict intracranial blood vessels, that really is reassuring in terms of the risks associated with these. That's something that is also a shift. Now, having said that, we have to practice a little defensively, unfortunately, because this stuff is still in the label. We have to think about what the risks are.
However, in general, again, getting away from the idea that our acute treatments are actually constricting brain blood vessels, I think, is very important. The newer ones, the CGRP-targeting therapies, do not directly constrict blood vessels. That's often made as a point in their favor. However, again, our idea that the triptans are risky drugs has really changed over the years based on clinical experience, but then also these imaging studies that challenge the idea that they're actively constricting blood vessels.
Subramanian: Wow. What a paradigm shift. It’s so interesting. Thank you so much, Andy. Thanks to everyone else out there for joining us.
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