Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA.
Headache. 2020 May;60(5):843-863. doi: 10.1111/head.13796. Epub 2020 Apr 4.
OBJECTIVE/BACKGROUND: Migraine is associated with ischemic stroke. Women are 3-fold as likely as men to have migraine, and high estrogen states increase the risk of migraine with aura (MWA), venous thromboembolism (VTE), and of stroke. We review the epidemiological and mechanistic evidence of the migraine-stroke relationship and its risk factors, with a focus on women and conditions that exclusively or predominantly affect them. METHODS: We performed a search of MEDLINE/PubMed database, then a narrative review of the epidemiological evidence of the migraine-stroke relationship as well as the evidence for arterial, thrombophilic, and cardiac mechanisms to explain this connection. We examine the implications of this evidence for the diagnostic evaluation and treatment of MWA.
MWA is associated with multiple stroke risk factors, such as hypertension, hyperlipidemia, diabetes mellitus, cigarette smoking, atrial fibrillation, and patent foramen ovale. In women, MWA is also associated with biomarkers of endothelial activation, hormonal contraceptive use, pregnancy, and VTE. This suggests that a subset of auras may be secondary, that is, induced by ischemia related to microemboli or in situ thrombosis. MWA-associated ischemic stroke is more common in young (<45 years old) women with high frequency of migraine attacks, hormonal contraception use, and with pregnancy and preeclampsia. There is increasing evidence that cardioembolism, often in conjunction with thrombophilia, plays a prominent role in MWA-associated cerebral infarction.
The commonality of factors associated with MWA and with MWA-associated stroke suggest that persons with secondary, ischemia-induced aura may be at elevated risk of stroke. Although further research is needed, we recommend consideration of a diagnostic evaluation of MWA that mirrors the evaluation of transient ischemic attack, given that prophylactic treatment targeting the ischemic origin of secondary aura may prevent migraine as well as stroke.
目的/背景：偏头痛与缺血性中风有关。女性患偏头痛的可能性是男性的 3 倍，而雌激素水平高会增加偏头痛伴先兆（MWA）、静脉血栓栓塞（VTE）和中风的风险。我们回顾了偏头痛与中风关系及其危险因素的流行病学和机制证据，重点关注女性和专门或主要影响她们的疾病。方法：我们在 MEDLINE/PubMed 数据库中进行了搜索，然后对偏头痛与中风关系的流行病学证据以及动脉、血栓形成和心脏机制的证据进行了叙述性综述，以解释这种联系。我们研究了这一证据对 MWA 的诊断评估和治疗的影响。结果：MWA 与多种中风危险因素有关，如高血压、高血脂、糖尿病、吸烟、心房颤动和卵圆孔未闭。在女性中，MWA 还与血管内皮细胞激活的生物标志物、激素避孕药的使用、妊娠和 VTE 有关。这表明，一部分先兆可能是继发性的，即与微栓塞或原位血栓形成引起的缺血有关。MWA 相关的缺血性中风在年轻（<45 岁）、偏头痛发作频率高、使用激素避孕药和妊娠及子痫前期的女性中更为常见。越来越多的证据表明，心源性栓塞，通常与血栓形成倾向一起，在 MWA 相关的脑梗死中起着重要作用。结论：与 MWA 和 MWA 相关中风相关的因素的共同性表明，继发性、缺血性先兆的患者可能有更高的中风风险。尽管需要进一步的研究，但我们建议考虑对 MWA 进行诊断评估，类似于对短暂性脑缺血发作的评估，因为针对继发性先兆缺血起源的预防性治疗可能预防偏头痛和中风。
