Is there a common biological pathway underlying ischemic stroke and migraine in young patients?
Among young patients with ischemic stroke, migraine was associated with cervical artery dissection (CEAD), according to the results of a study published recently in JAMA Neurology.1
“This association persisted after adjustment for traditional vascular risk factors, and it was apparent for the migraine subtype without aura more than for migraine with aura, for men more than for women, and for the younger rather than older age group,” wrote Valeria De Giuli, MD, of the Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, UniversitÃ degli Studi di Brescia, Brescia, Italia, and colleagues. “Our data support consideration of a history of migraine as a marker for increased risk of ischemic stroke caused by CEAD, as well as a putative susceptibility factor for CEAD, regardless of its clinical features.”
The study looked at 2,485 consecutive patients aged 18 to 45 with first-ever acute ischemic stroke taken from the Italian Project on Stroke in Young Adults. Frequency of migraine and presence or absence of aura was assessed. The researchers looked at presence of migraine in patients whose stroke was because of CEAD or from another cause and the characteristics of CEAD-related stroke with or without migraine.
Of the included patients, 13.4% had CEAD ischemic stroke. Migraine occurred more commonly in patients with CEAD stroke compared with non-CEAD stroke (30.8% vs. 24.4%; P=0.01). Data showed that the difference in incidence of migraine was mainly from migraine without aura (24.0% vs. 15.6%; P<0.001). In fact, compared with migraine with aura, migraine without aura was independently associated with CEAD-related stroke (odds ratio=1.74; 95% CI, 1.30-2.33). The association between migraine without aura and CEAD stroke was stronger in men (OR=1.99; 95% CI, 1.31-2.33) and in patients aged 39 or younger (OR=1.82; 95% CI, 1.22-2.71). Frequency of migraine with aura did not differ between the two groups.
“The mechanisms by which migraine might increase the individual propensity to CEAD remain unproven, but there are convincing arguments for common biological pathways underlying the 2 disorders,” the researchers wrote. “Among these, shared genetic susceptibility and endothelial dysfunction seem to be plausible.”
In an editorial that accompanied the study, Patrick D. Lyden, MD, of the department of neurology at Cedars-Sinai Medical Center, discussed several strengths of the study.2
“The investigators assiduously searched for multiple stroke causes in each young patient and diligently recorded their observations. Rigorous work is needed to study patients with both migraine and dissection, compared with patients without either disease, and examine agnostically for biological mechanisms in common,” the researchers wrote. “Furthermore, there is the remaining chance that the association between migraine without aura and dissection is just that-chance. Future studies should focus not only on confirming the finding-which really seems robust given the large sample size and thorough evaluation-but also on analyzing biochemical or histologic features in common.”
1. De Giuli V, et al. Association between migraine and cervical artery dissection. The Italian Project on Stroke in Young Adults. JAMA Neurol. Epub 2017 March 6.
2. Lyden PD, et al. Migraine and the risk of carotid artery dissection in the IPSYS Registry. Are they related?JAMA Neurol. Epub 2017 March 6.