S2:Ep17 – The Relationship Between Migraine and Stroke

TRANSCRIPT

Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease. This episode is brought to you by our generous sponsor, Teva Pharmaceuticals.

We know that migraine and stroke are both brain disorders, but what else do they have in common? Headache and stroke specialist Dr. Huma Sheikh explains the relationship between these two conditions. Dr. Sheikh discusses risk factors, how to distinguish symptoms, tips for reducing stroke risk, the impact of oral contraceptives, and more.

Teva is committed to providing innovative medicines to enable people, including those living with migraine, to live better days. Teva applies a holistic approach to the development of new treatments that focus on the needs of patients. Visit TevaPharm.com to learn more.

Molly O’Brien: Hello, and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. Today we’re taking a look at the relationship between migraine and stroke. Some stroke symptoms resemble a migraine attack, so how can we tell the difference between the two? We’ll look at that and much more in today’s episode.

I’d like to introduce our guest, Dr. Huma Sheikh. She’s a neurologist with specialization in headache and stroke. Dr. Sheikh, thanks so much for joining us today.

Dr. Huma Sheikh: Thank you. Thank you for having me. It’s a great opportunity to be able to get out some good education.

Molly: So as we get started, before we jump into the migraine part, can you just tell us a little bit about what stroke is, what’s actually happening, how it’s defined?

Dr. Sheikh: Sure. So stroke is a little bit analogous to a heart attack, except it’s happening in the brain. And there are two main types of stroke: one is called ischemic, and the other is called hemorrhagic. And ischemic is much, much more common. It’s about 80 percent of all strokes. And hemorrhagic is about 15 to 20 percent. 

And essentially, in ischemic stroke, what is happening is that there is a blood vessel that provides blood to a certain part of your brain that can become basically closed off. So it can develop a clot in itself, or a clot can travel from somewhere else and close off that blood vessel so there’s no longer blood coming to that part of the brain. And if that happens for a certain amount of time, the brain is no longer able to function and may ultimately die in that area. So it can have very devastating effects. Thankfully — we might delve into this a little bit — we do have a lot of different treatments, but honestly, the best thing you can do is prevention.

Molly: Now that we’re a little more educated on what’s actually happening with stroke, it will help us get into that relationship between migraine and stroke. So as we look at that, are stroke and migraine related in any way, and if so, what is their relationship?

Dr. Sheikh: Yeah, so we have a lot of research now, and we do know that migraine and stroke are related in a few different ways. So the first is that migraine and stroke are both diseases that are primarily happening in the brain. The other relationship that we know between migraine and stroke is that there are some people who have migraine who are at higher risk of having a stroke. And we think this happens with a specific type of migraine that is called migraine with aura. 

So there’s a lot of research now to show that people — or, especially women; most of the studies have been done in women because migraine is so much more common in women — that if you have a subtype of migraine called migraine with aura, you do have a slightly higher risk of having a stroke. Thankfully, that absolute risk is very, very small, and there’s lots of different things that we can do to help prevent a stroke, but that risk is there. The question is, well, why? And so we’re still trying to figure that out, but we have seen that relationship there in multiple studies now.

Molly: And we hear a lot about that — you just mentioned it — migraine with aura and stroke. And you said we’re starting to learn more about the relationship between the two. What do you think needs to happen to make a solid connection, or what else do we need to know about the two?

Dr. Sheikh: Yeah, so one of the biggest reasons that we don’t have a lot of great information — and, actually, it’s in one way a good thing — is that it doesn’t happen often. So women that have migraine, the majority of them will not have a stroke. And so that’s a good thing, but what makes that harder is to study it because it’s a rare thing that happens.

So what would be ideal is to be able to collaborate with all over the United States and all over the world so that we have enough patients that we’re able to study. I think the more patients you have, the more information you’re able to get. So collaboration with headache centers and stroke centers would be really, really a great thing, and they’re starting to develop that. I think the American Headache Society is developing a registry, and that’s going to be one of the things that they’re looking at to help define why women with migraine have increased cerebrovascular risk. 

But also we need funding. Things like migraine aren’t as well funded as other diseases, so obviously, that would be also really great is to be able to have funding to be able to study what are the underlying risk factors that migraine produces in order to cause this increased risk of stroke.

Molly: And you mentioned right there that women are more susceptible or at a higher risk. Can you explain why that is? We know that more women have migraine, but is there any kind of relationship, and are there certain groups of women with migraine who have a higher risk?

Dr. Sheikh: Yeah, so the studies that have been done so far, the two biggest links that we have found is the fact that women do have migraine at much, much higher rates — it’s about three to four times more in women than men — and women tend to have more severe and frequent migraines when they have that diagnosis. So we know that migraine is something like asthma, right? So you have this underlying predisposition, and then environmental triggers can bring out the actual episodes of migraine. So for women, hormonal changes, either monthly or when they’re going through menopause or pregnancy, play a big role in triggering migraine. 

And then the other thing that we have found a link with is hormonal contraceptives. So when we have our own intrinsic hormonal changes, from either month to month or when we’re going through a change like pregnancy or menopause, that can affect your stroke risk. But also if you take extrinsic hormones, there might be this added risk. And we have some studies to show that women that have migraine who also take oral contraceptives, that might be one other thing that might add to their stroke risk. 

I say this with a little bit of pause because a lot of that information is not updated, unfortunately. The studies were done in the seventies, early eighties, and at that time, women were taking hormones — especially the estrogen component, were much, much higher than we do today for hormonal contraceptives. So whether or not that relationship is still there is not very clear, but that’s the information that we have right now.

So it can be very tricky if we have a woman who has migraine with aura and needs to be on birth control. That’s a situation where it’s really important to sit down and look at all the evidence and have a really thorough discussion with the patient.

Molly: And kind of staying on that topic, one of your main areas of research is looking at the link between women who take oral contraceptives and risk of stroke. So we know that a lot of the research done before was a while ago and a little out of date, like you mentioned. But as you look into this type of research, what else can you tell us about the link between the two, and is it super significant that we need to worry about it?

Dr. Sheikh: Yeah, so that’s a really great question because, I think, we get this question a lot from GYN, primary care doctors, patients themselves who need to be on birth control either for pregnancy prevention or other diseases. And migraine is so common — one in seven women will have migraine — so the overlap between having migraine and needing to be on birth control, it’s going to happen. 

So there are other possible things that can add to the risk, and I think one thing that we can really do to help decrease the risk is making sure that you’re trying to be as healthy as possible otherwise. So we know that smoking really, really adds to that risk, so if you’re a smoker or if you’re thinking about smoking, that’s something you really want to seriously think about cutting out. And that can really, really decrease the risk of stroke even if you have migraine with aura. And then also keeping your blood pressure under really good control. So those are two things that you can actually do to decrease the risk yourself, because those have also been found to add to the risk of stroke in young women with migraine.

And then it really depends on why you’re deciding to take the hormonal contraception. If it’s for pregnancy prevention, we know that there are other methods that you can try that are also safer than hormones. And we know that it’s the estrogen component that adds to the stroke risk, so if you’re comfortable taking just a progesterone-only hormone contraceptive, that’s a safe alternative as well. So there are things that we can do to get around it. 

But also, like you mentioned, just to keep it in perspective, in absolute numbers, the risk of having a stroke if you have migraine with aura and you’re also on a contraceptive is about 1 in 400,000 to 500,000. So it’s really, really, really low. The other reassuring thing is, that also — I mean, it depends on how reassuring you feel this is, but if a stroke were to happen, they tend to be very small. But obviously, the goal for us is to prevent stroke altogether. 

But I do give patients that number, 1 in 400,000 to 500,000, because the other statistic is that women with migraine with aura who do take oral contraceptives, their risk of having a stroke is two times of someone who doesn’t have migraine at all. And so that can feel like a big number, like, “Wow, it’s double my risk.” But in absolute numbers, when you actually look at the numbers who actually have a stroke, it’s much, much, much lower.

Molly: I think that’s so good to be able to put those numbers into perspective, yeah, because when you say, that double the risk, that’s overwhelming and alarming. But once you look at the true numbers, it definitely does put it in perspective. So thank you for that.

So stroke symptoms — or, stroke-like symptoms, I should say, sometimes appear during a migraine attack. So how can one with migraine know and understand and tell the difference between they’re having a stroke or if they’re having a migraine attack?

Dr. Sheikh: Yeah, so that’s a really great question. So the type of migraine that we’re talking about where you may have stroke-like symptoms is, again, migraine with aura. And so it’s the aura that may feel like it’s something scary or dangerous going on. And essentially, there are three big types of aura. The most common is visual, where someone might describe that on one field of their vision, so one side of their vision in both eyes, they might see colors like a kaleidoscope. They might see lightning rods in one field of their vision. And the important thing to try to tease out is the fact that it starts small, it starts in one corner, and then grows over time, typically somewhere between 15 to 30 minutes.

The other type of aura is a sensory aura, where you will start to feel tingling on one side of your face, and then it can go into your arm and your leg. Or it might just be in your hand and then go up into your arm and shoulder and then into your face. And then the last type is what we call motor aura, where you might start to feel like one side of your body is feeling weak. So it might start in your hand and then the entire arm, or you might notice that one side of your face feels weak.

So some of these symptoms — I mean, if you are a young 20-, 21-year-old woman and it’s your first migraine with aura and you start to feel one side of your body becoming numb or weak or seeing these spots or colors in your vision, that’s very scary. And if someone is having this for the first time, my recommendation would be to go to the ER. 

A lot of women, they are having their visual auras for many years; it’s very, very similar each time, what we call “stereotyped”; and they know it’s going to last 15, 20 minutes, and then they get their typical headache. So if it’s been happening and it’s very stereotyped, like it always happens, that’s very reassuring. But the first time around, it can be scary. It’s hard to know the difference.

Some of the ways that we know the difference is that migraine aura tends to grow. So like I mentioned, the visual aura will start very small and then grow over time, the sensory aura will start in one space and then slowly grow, whereas stroke happens quickly all at once. If you have eye symptoms with your stroke, you’re going to go blind in seconds flat. It’s not going to evolve over minutes. So that’s one way you can help to distinguish.

A second way is that aura tends to be what we call positive symptoms, whereas stroke tends to be negative symptoms. So with a stroke, you lose your sensation, so you feel numb, whereas with an aura, you’ll feel tingling. Same thing with the vision — you’re actually seeing colors or lights. With a stroke, that’s very, very rare — very, very rare that that would happen. It’s more a loss of vision.

Molly: I think those few pointers that you gave us about just really slight differences to help differentiate migraine attack and stroke, it makes a world of difference, because the symptoms are so eerily similar, it can be frightening. But if you know yourself, you know your body, and you can take just kind of those two pieces of advice to differentiate, that, to me, makes a world of difference.

Dr. Sheikh: Yeah, I agree. Yeah, I think so many migraine patients after so many years of having it know themselves so well, and they can know when something is different and off. So that’s the most important thing is — yeah, is actually paying attention and staying in tune. Yeah, I agree.

Molly: And the other part of that is migraine can grow, evolve, and change. I know, personally, I’ve had symptoms that pop up that I’ve never had before, and it is frightening, and they can resemble stroke. So I think those are really good pieces of advice.

You talked a little bit about some of the symptoms that are very similar between stroke and migraine, migraine with aura. Can we look at the subcategory of hemiplegic migraine, because the symptoms, again, are so similar? What can patients with hemiplegic migraine look out for, and can they do anything to differentiate the two?

Dr. Sheikh: Yeah, so hemiplegic migraine is one of the subtypes that we mentioned in migraine with aura that have motor symptoms as your aura. And this can be one of the most frightening because you can be weak. You might not be able to walk because your leg is so weak while you’re having a migraine. You might not be able to move your leg. You can have difficulty speaking because one side of your mouth is weak or drooping. And for someone who doesn’t know that you have a migraine, this can look exactly like a stroke. So it can be scary for yourself as well as people that are around you. 

Hemiplegic migraine is one of the migraine disorders where we actually do know the underlying genetic makeup, so that can be really helpful because you can actually get the diagnosis and know for sure that that’s what it is.

Molly: I’m curious — because we’re trying to get our headache attacks under control, or migraine attacks — are there any certain medications that can help reduce the risk of stroke?

Dr. Sheikh: So, in general, if you do have risk factors for stroke, we do start an antiplatelet, so something like aspirin or Plavix. It’s a little controversial if your only risk factor is migraine. So if you come to your doctor and you have a history of migraine but you also have high blood pressure or diabetes, or you’re a smoker who hasn’t quit yet, starting aspirin is a very good way to decrease your risk of a stroke. If your only risk factor is migraine, so far, we haven’t found that adding on aspirin is beneficial. But it’s a discussion to have with your doctor, whether or not adding on an antiplatelet is a good idea.

In addition to the Aspirin, keeping your cholesterol and maybe adding on a cholesterol medication might also be helpful.

Molly: So, Dr. Sheikh, we’ve been talking a lot about how having migraine could increase the risk for having a stroke. But let’s kind of flip that upside down. Does having a stroke increase your risk for developing migraine?

Dr. Sheikh: Yeah, so great question. So the answer is indirectly, yes. There are a few studies, small studies, that show that if you have a stroke, you can go on to develop migraine or headaches. Headaches in general is much more common. They’re not always necessarily classified as migraine because migraine is a primary disorder. 

So sometimes a headache can be an indication that you’re having a stroke. If you have something called a hemorrhagic stroke, where one of the blood vessels in the brain ruptures and there’s bleeding into the brain, that’s very irritating to the brain. And so you will have a bad headache. So if you’re someone who never gets headaches, doesn’t have a history of migraine, and you have a really bad headache — sometimes it’s called the worst headache of your life — that is an indication that you should call 911 immediately. And that can be an indication that you’re having a stroke.

But other people who have a stroke, especially if it’s in the back of your brain — we call it the posterior region — because the brain is now — there might be an area that is scarred and is no longer viable, the neurons around there have to adjust to this new normal, and sometimes they can be hyperreactive. They can become irritable, and that can develop headaches down the line. So it can be a consequence of stroke. Thankfully, it’s not very common, but there are some cases of that. 

The other situation in which a stroke can cause headaches is in something called carotid dissection. So that’s not necessarily in the brain itself, but if one of the major arteries — the carotids or the one in the back, called the vertebrals — develops a tear, and this can happen, actually, in young people if you have a neck injury, if you have a whiplash injury, or if you’re playing sports and you turn around very quickly, one of the major arteries can tear, and that’s called a dissection. And that technically is a type of stroke. 

And that can present with a really bad headache. Especially if it’s in the carotid, it can present with a headache on that same side but also into the jaw and face. If it’s in the back, in the vertebral, that can cause a really bad headache in the back of the head. And that’s a tear in your artery that can heal over time, but in the meantime, you can develop headaches from that that can be, unfortunately, a little bit hard to treat because the blood vessels have, again, a lot of nerve endings around it. And so now that there’s a tear, those nerve endings can become irritable and sensitive.

So, yeah, it can unfortunately go both ways: a stroke can lead to headaches, and the primary headache disorder migraine can very rarely increase the risk of stroke as well.

Molly: It’s fascinating to know how the two are related, and we’ve covered so much information, so I really appreciate it, and all good strategies to look out for, whether you’re a migraine patient or not.

Dr. Sheikh, thank you so much for joining us today and for giving us a wealth of information on the relationship between migraine and stroke. We’re happy to have you here today.

Dr. Sheikh: Thank you for having me. It was a wonderful opportunity.

Molly: And if you want any more information between the relationship of stroke and migraine or if you have questions, you can reach out to Dr. Sheikh via her website or social media. You can also take a look at the wealth of information we have at MigraineDisorders.org.

Until next time, I’m Molly O’Brien, and thanks for watching Spotlight on Migraine.

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