Migrainous Infarction

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Dec 5, 2021
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  • Defined as a stroke that occurs along with a migraine headache.
  • Migraines that fit the criteria for migrainous infarction;
    • The migraine must be associated with an aura; the symptoms of which must last longer than 60 minutes.
    • The migraine attack must be similar in intensity to the previous migraines.
    • The symptoms of the aura must correlate to the area of the brain where the stroke has occurred.
    • Any other medical condition should not be the cause of the stroke
Migrainous Infarction is Defined as a stroke that occurs along with a migraine headache
  • Migraines with aura have two-folds increased risk of ischemic stroke
  • Migrainous infarction accounts for 0.2%-0.5% of all ischemic strokes
  • Of Note, 18.6% of Stroke have associated headache as presenting symptoms


  • Incidence rate ranges from 1.44 to 1.7 per 100,000 persons per year
  • Individuals with migraines with aura have two-folds increased risk of ischemic stroke
  • The risk increases with increasing migraine attack frequency.
  • Women affected more commonly, particularly younger age group.
  • Visual aura is the most commonly associated feature.
  • Posterior circulation is more frequently affected.
  • Migrainous infarction accounts for 0.2%-0.5% of all ischemic strokes.


  • The exact cause of migrainous infarction is still not certain.
  • Spasm of vertebral or carotid arteries leading to cerebral hypo-perfusion is an important underlying mechanism.
  • Increased platelets activation during migrainous attack increases the risk of thrombosis.
  • Platelet activation is enhanced in patients with migraines with aura, even during aura-free and headache-free periods.
  • Genetic associations between stroke and migrainous infarction
    • Polymorphism in the MTHFR (methylenetetrahydrofolate reductase) gene.
    • Angiotensin converting enzyme gene deletion polymorphism (ACE-DD).
  • Endothelial dysfunction
    • Reduction in vasodilator activities
    • Increased endothelial-derived vasoconstriction
  • Coagulation abnormalities
    • Increased Platelet-activating factor (PAF)
    • Increased von Willebrand Factor (vWF)
    • Decreased resistance to activated protein C
    • Protein S deficiency
Precipitating Factors
  • Overdose of Ergotamine and dihydroergotamine ; can causes constriction of the cerebral vessels.
  • High dose Oral Contraceptives Pills
  • Propranolol; permanent neurologic deficits.
  • Serotonergic Medications; induce ischemic stroke.

Risk Factors

Female gender
Age <45 years
History of migraine with aura
Diabetes Mellitus
Oral Contraceptives

Diagnostic Criteria

Diagnostic Criteria for Migrainous Infarction by International Classification of Headache Disorders (ICHD-3 1.4.3)
The following Criteria needs to be met for diagnosis of
Criteria A
  1. A migraine attack fulfilling criteria B and C
  1. Occurs in a patient with migraines with aura where the aura symptoms persist for more than 60 minutes
  1. Neuroimaging demonstrates ischaemic infarction in a relevant area
  1. Not better accounted for by another ICHD-3 diagnosis.
Of Note: There may be additional symptoms attributable to the infarction

Figure 1: Typical manifestation of migrainous infarct

notion image
Typical manifestation of migrainous infarct on MRI diffusion weighted in a 45-year-old female patient with chronic migraine with aura.

Differential Diagnosis

  • Other sources of Ischemic Stroke
  • Idiopathic thunderclap headache
  • Arterial dissection
  • Intracranial neoplasm
  • Arteriovenous malformation

Treatment and Management

  • Prevention of stroke in Migraineurs
    • Risk factor modification
      • Smoking cessation
      • Abstinence of Oral Contraceptives
  • Prophylaxis in Migraineurs at risk for Ischemic CVA
    • Beta-adrenergic Blocker
    • Calcium Channel Blocker; Nifedipine
    • Angiotensin-receptor Blocker
    • ACE Inhibitors
    • Statins
    • Aspirin


  • Permanent neurological deficits.
  • Recurrent episodes of stroke
  • Bleeding disorder due to medication side effect.


  • Depends on the timely treatment of migrainous infarction which can prevent permanent neurological deficits.
  • In majority of the patients that present with prolonged visual auras, and the stroke severity is mild with good short-term and long-term outcomes.


  • It is imperitive to raise more awareness regarding the association of migraine and stroke and the close association between the two.
  • Further studies are needed to determine more aggressive preventive measures of migraine.
  • Early identification of risk factors will decrease the risk of migraine associated stroke.

Further Reading


  • Wang SJ. Migrainous infarction. MedLink Neurology. Updated 02.28.2021 Released 07.01.1993 EXPIRES FOR CME 02.28.20
  • Kreling GAD, Almeida Neto NR, Santos Neto PJ. Migrainous infarction: a rare and often overlooked diagnosis. Autops Case Rep [Internet].2017;7(2):6168.
  • Milhaud D, Bogousslavsky J, van Melle G, Liot P. Ischemic stroke and active migraine. Neurology 2001;57:1805-1811.
  • Ahmadi Aghangar, A., Bazoyar, B., Mortazavi, R., & Jalali, M. (2015). Prevalence of headache at the initial stage of stroke and its relation with site of vascular involvement: A clinical study. Caspian Journal of Internal Medicine6(3), 156–160. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4650791/
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