Migraine: Leading Cause of Improper t-PA Use

The study found that migraine with aura represented the third main cause of improper thrombolytic treatment, after seizures (30%) and conversion/psychiatric disorders (over 25%). Yet, given that the risk of adverse events remains very low, the authors advise administration of recombinant plasminogen activator (t-PA) when the clinical diagnosis is uncertain.

“A detailed clinical evaluation is necessary to achieve a correct diagnosis. When this is not possible, in front of persistent clinical doubt it is advisable to proceed with t-PA administration, given the multiple evidences of its safety in scientific literature. Emergency brain MRI may surely reduce misdiagnosis, but at the dangerous price of a procrastination of a potentially life-saving therapy,” wrote lead author Ferdinando Maggioni, MD, of the University of Padua, Italy, and colleagues.

Many symptoms of migraine and stroke overlap, and differentiating between the two can be clinically challenging. Migraines sufferers are also at increased risk for ischemic stroke, further muddying the picture.

Timely administration of t-PA (within 4.5 hours of stroke onset) can be potentially disability- and life-saving. Because “time is brain,” efforts at improving stroke treatment have stressed earlier treatment, with the result that inappropriate t-PA use may be on the rise. Yet t-PA carries rare but serious risks, including brain hemorrhage. The rarity of such side effects in stroke with migraine is sometimes used as justification for using t-PA. Faced with a young patient whose diagnosis is uncertain, some clinicians may choose the lesser of two evils.

How safe is t-PA in stroke mimics like migraine? To find out, researchers searched PubMed for studies that compared stroke mimics treated with thrombolytics vs those not treated with thrombolytics. Included articles were published after 1995, and were limited to English only. The analysis included 35 studies.

Limitations: The analysis included articles that varied widely in their methods and results, which could have limited the study. Rates of stroke evaluation with the final diagnosis of migraine may vary by center, with lower rates at centers with access to neurologists and higher rates where non-neurologists perform stroke evaluations.