Migrainous Infarction

Ashina Khalid Rana (1), Muhammad Umair (2), Dr. Junaid Kalia (3)
  1. Sharif Medical and Dental College, Lahore
  1. Shaikh Khalifa Bin Zayed Al Nahyan Medical and Dental College, Lahore
  1. Founder, AINeuroCare


Introduction

  • 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
 

Epidemiology

  • 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.

Pathophysiology

  • 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
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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

Table 1: Risk Factors
Non-modifiable
Modifiable
Hyperlipidemia
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

Figure 1: Typical manifestation of migrainous infarct on MRI diffusion weighted in a 45-year- old female patient with chronic migraine with aura.
Figure 1: Typical manifestation of migrainous infarct on MRI diffusion weighted in a 45-year- old female patient with chronic migraine with aura.
Source: Zhang, Y., Parikh, A., & Qian, S. (2017). Migraine and stroke. Stroke and Vascular Neurology2(3), 160-167. https://doi.org/10.1136/svn-2017-000077

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

Complications

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

Prognosis

  • 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.

Conclusion

  • 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

Bibliography

  • 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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