Stroke and Chest Pain in Young People With Migraine
Background: Cerebrovascular and cardiovascular complications in migraineurs may be part of the migraine process and also consequent to triptan treatment.
Aim: To determine the frequency, subtypes and associations of migraine-associated stroke and angina in young people (18-49 years).
Methods: Patients were derived from a tertiary referral migraine and stroke registry. Migraine-associated stroke was classified according to the four groups described by Welch and by the TOAST etiological stroke classification. A clinical description of angina during a migraine attack was required for the diagnosis of cardiac migraine without concomitant triptan or other vasoactive medications
Results: Of the young patients with stroke (349/1316; 26.5%), there were 30 (30/349; 8.6%) who had migraine at the time of stroke when categorized by the Welch classification type II to IV (type II n = 5, type III n = 2, type IV n = 3). Comparison of type I (n = 20) versus types II-IV (n = 10) showed significant difference (P= .03). Topographically the lesions were distributed into the partial anterior circulation (n = 8) and posterior circulation (n = 2) (P= .04). Comparison of anterior and posterior circulation territories of infarction indicated significant difference (n = 26/30 and 4/30; P= .01). The stroke etiological subtypes included cardiogenic (n = 5), atherogenic (n = 15), other (n = 5), and unknown (n = 5), with none diagnosed with small-vessel cerebrovascular disease. Traditional stroke mechanistic entities (cardiac and atherogenic) differed significantly in comparison to the other and unknown categories P= .05. Cardiovascular patients with angina during a migraine attack (n = 9/1040; 0.9%), included IHS subtypes; migraine without aura (n = 4), migraine with aura (n = 4), and complicated migraine (n = 1). One patient required cardiac catheterization on account of significant ECG changes, with documented, reversible vasospasm.
Conclusion: (i) Migraine-induced stroke remains controversial, with only two probable cases of type Welch III A+B in a large registry. (ii) Cardiac migraine may be a distinct entity requiring careful differentiation from triptan-induced chest pain.
Cerebrovascular and cardiovascular events are among the most feared complications of migraine and triptan treatment. With triptans now being the preferred method of migraine treatment, vascular complications need to be viewed more critically. Furthermore, the vascular bed specificity of triptans is especially pertinent to the cerebrovascular and cardiovascular systems.
The migraine process itself may have cerebrovascular and cardiovascular sequelae. The pathophysiology of migraine-related stroke however is a controversial, poorly understood entity. Whether migraine acts as a risk factor for stroke on its own remains controversial. Paradoxical embolism has been the presumed cause in many reported cases. Recent evidence that patent foramen ovale closure or anticoagulation may abate migraine with aura in up to half of the patients gives credence to the concept of stroke masquerading as migraine. Other stroke mechanisms such as the stroke serotonin syndrome may likewise be cast under the rubric of migraine stroke. A comprehensive cardiovascular and cerebrovascular workup often reveals comorbid conditions, blurring the distinctions.
From a cardiovascular point of view, chest pain during migraine is rare in clinical practice. There are reports dating back to 1974 of angina during migraine attacks. There is a speculative relationship between migraine, coronary spasm, and myocardial infarction, but a recent large study found that migraine is not an independent risk factor for coronary heart disease in middle-aged and older people.
Abstract and Introduction
Abstract
Background: Cerebrovascular and cardiovascular complications in migraineurs may be part of the migraine process and also consequent to triptan treatment.
Aim: To determine the frequency, subtypes and associations of migraine-associated stroke and angina in young people (18-49 years).
Methods: Patients were derived from a tertiary referral migraine and stroke registry. Migraine-associated stroke was classified according to the four groups described by Welch and by the TOAST etiological stroke classification. A clinical description of angina during a migraine attack was required for the diagnosis of cardiac migraine without concomitant triptan or other vasoactive medications
Results: Of the young patients with stroke (349/1316; 26.5%), there were 30 (30/349; 8.6%) who had migraine at the time of stroke when categorized by the Welch classification type II to IV (type II n = 5, type III n = 2, type IV n = 3). Comparison of type I (n = 20) versus types II-IV (n = 10) showed significant difference (P= .03). Topographically the lesions were distributed into the partial anterior circulation (n = 8) and posterior circulation (n = 2) (P= .04). Comparison of anterior and posterior circulation territories of infarction indicated significant difference (n = 26/30 and 4/30; P= .01). The stroke etiological subtypes included cardiogenic (n = 5), atherogenic (n = 15), other (n = 5), and unknown (n = 5), with none diagnosed with small-vessel cerebrovascular disease. Traditional stroke mechanistic entities (cardiac and atherogenic) differed significantly in comparison to the other and unknown categories P= .05. Cardiovascular patients with angina during a migraine attack (n = 9/1040; 0.9%), included IHS subtypes; migraine without aura (n = 4), migraine with aura (n = 4), and complicated migraine (n = 1). One patient required cardiac catheterization on account of significant ECG changes, with documented, reversible vasospasm.
Conclusion: (i) Migraine-induced stroke remains controversial, with only two probable cases of type Welch III A+B in a large registry. (ii) Cardiac migraine may be a distinct entity requiring careful differentiation from triptan-induced chest pain.
Introduction
Cerebrovascular and cardiovascular events are among the most feared complications of migraine and triptan treatment. With triptans now being the preferred method of migraine treatment, vascular complications need to be viewed more critically. Furthermore, the vascular bed specificity of triptans is especially pertinent to the cerebrovascular and cardiovascular systems.
The migraine process itself may have cerebrovascular and cardiovascular sequelae. The pathophysiology of migraine-related stroke however is a controversial, poorly understood entity. Whether migraine acts as a risk factor for stroke on its own remains controversial. Paradoxical embolism has been the presumed cause in many reported cases. Recent evidence that patent foramen ovale closure or anticoagulation may abate migraine with aura in up to half of the patients gives credence to the concept of stroke masquerading as migraine. Other stroke mechanisms such as the stroke serotonin syndrome may likewise be cast under the rubric of migraine stroke. A comprehensive cardiovascular and cerebrovascular workup often reveals comorbid conditions, blurring the distinctions.
From a cardiovascular point of view, chest pain during migraine is rare in clinical practice. There are reports dating back to 1974 of angina during migraine attacks. There is a speculative relationship between migraine, coronary spasm, and myocardial infarction, but a recent large study found that migraine is not an independent risk factor for coronary heart disease in middle-aged and older people.
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