Migraine natural history, complications and prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]


Migraine with aura is associated with increased risk of subsequent stroke, a risk further amplified among females, smokers, patients on OCP and patients suffering from frequent migraine episodes. Despite the elevated risk of stroke among patients with migraine associated with aura, the incidence of stroke in this category of patients remain low particularly in young adults. Patients with migraine not associated with aura are not at an increased risk of stroke compared to the general population.[1]


  • Status migrainosus: The migraine episode lasts more than 72 hours.
  • Persistent aura without infarction: The symptoms of aura last for more than a week in the absence of any neuroimaging findings suggestive of infarction.
  • Migrainous infarction: The symptoms of aura last for more than a week in the context of any neuroimaging findings suggestive of infarction in the corresponding brain territory.
  • Seizure triggered by a migrainous aura[2]

Migraine and Stroke

The association between migraine and increased risk of subsequent stroke has long been suspected.[3] In fact, migraine with aura is associated with two times increase of ischemic stroke, while migraine without aura was not demonstrated to be linked to an increased risk of subsequent stoke. Although patients suffering from migraine with aura are at a double risk of ischemic stroke, the incidence of stroke remains a rare event particularly among young adults. The risk of subsequent stroke is higher among females and among patients suffering from a high frequency of migraine with aura episodes.[4] Some risk factors that predispose to stroke among migraine patients are smoking, OCP use and genetic mutations.[3][5][6] In addition, patients with patent foramen ovale and migraine are at increased risk of stroke. Closure of patent foramen ovale has been reported to improve migraine and therefore decrease the risk of subsequent stroke episodes; however, randomized clinical trials failed to demonstrate these benefits.[1]

The link between stroke and migraine is far more complicated than a simple risk or predisposition relationship. Migraine, as well as of stroke, involves changes in the vascular and neuronal structure of the brain. Therefore, it is difficult to differentiate whether stroke is a result of the aura of the primary migraine, or if it results from vascular abnormalities predisposing to both migraines and strokes. Some of the vascular abnormalities that are associated with migraines are AV malformations, moyamoya syndrome, hereditary telengectasia, lupus, antiphospholipid syndrome, cardiac myxoma among other vascular medical conditions. It is worth mentioning that migraine was not only associated with ischemic strokes, but also hemorrhagic strokes and lacunar infarcts.[1]

In addition, the underlying pathophysiology of aura is explained by a synchronized depression of the activity of neurons throughout the cortex of the brain causing not only electrolyte changes but also decrease in the cerebral blood flow. This decrease in the cerebral flow lowers the threshold for ischemic stroke. And vice versa, a decrease in the cerebral blood flow as in the case of hypoperfusion, ischemia or embolism leads to cellular changes predisposing to aura. This adds to the complexity of the association between stroke and migraine, which remains unclear.[1]


Many patients with migraine can relieve pain and reduce frenquency with treatments.


  1. 1.0 1.1 1.2 1.3 Kurth T, Chabriat H, Bousser MG (2012). "Migraine and stroke: a complex association with clinical implications". Lancet Neurol. 11 (1): 92–100. doi:10.1016/S1474-4422(11)70266-6. PMID 22172624.
  2. Headache Classification Committee of the International Headache Society (IHS) (2013). "The International Classification of Headache Disorders, 3rd edition (beta version)". Cephalalgia. 33 (9): 629–808. doi:10.1177/0333102413485658. PMID 23771276.
  3. 3.0 3.1 Etminan M, Takkouche B, Isorna FC, Samii A (2005). "Risk of ischaemic stroke in people with migraine: systematic review and meta-analysis of observational studies". BMJ. 330 (7482): 63. doi:10.1136/bmj.38302.504063.8F. PMC 543862. PMID 15596418.
  4. Merikangas KR, Fenton BT, Cheng SH, Stolar MJ, Risch N (1997). "Association between migraine and stroke in a large-scale epidemiological study of the United States". Arch Neurol. 54 (4): 362–8. PMID 9109736.
  5. Tzourio C, Tehindrazanarivelo A, Iglesias S, Alperovitch A, Chedru F, d'Anglejan-Chatillon J, Bousser MG (1995). "Case-control study of migraine and risk of ischaemic stroke in young women". BMJ. 310 (6983): 830–3. PMID 7711619.
  6. Kurth, T (2006). "Migraine and risk of cardiovascular disease in women". Journal of the American Medical Association. 296 (3): 283–91. PMID 16849661. Unknown parameter |month= ignored (help); Unknown parameter |coauthors= ignored (help); |access-date= requires |url= (help)

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