Migraine and Spontaneous Coronary Artery Dissection (SCAD)

Written by: Kylie Petrarca, RN, BSN

Medically Reviewed by: Bryan J Wells, MD

Edited by: Melissa Calise and Leigh Serth

What is Spontaneous Coronary Artery Dissection?

Spontaneous coronary artery dissection (SCAD) is a rare cardiovascular condition that is more prevalent in women.¹ According to the SCAD Alliance, ​​the inner lining of the coronary artery splits and allows blood to seep into the adjacent layer, forming a blockage (hematoma) or continuing to tear, creating a flap of tissue that slows or blocks blood flow in the artery (see the video below for a visual explanation).² Consequently, a person can experience a heart attack, changes in heart rhythm and/or cardiac arrest. The severity of the blockage can vary and so can the extent of symptoms.

Signs and symptoms of a heart attack include: chest pain, shortness of breath, nausea, indigestion, fatigue, anxiety, lightheadedness, dizziness, palpitations, back, jaw and/or arm pain. Symptoms of a heart attack should be reported immediately to 911.

SCAD is diagnosed using a variety of tests. Lab work can detect troponin levels in the blood, which will rise during an injury to the heart. An ECG is also performed to check the electrical signal of the heart. SCAD may be visualized by a CT scan with contrast (CT coronary angiogram) but the gold standard for diagnosis is a cardiac catheterization. Doctors may use intravascular ultrasound (IVUS) or optical coherence tomography screening to create pictures and confirm the SCAD diagnosis during the cardiac catheterization. 

Typically heart attacks are caused by the buildup of plaque in an artery leading to a blockage, which is not the case for SCAD. Various predisposing conditions have been identified including “fibromuscular dysplasia (FMD), pregnancy, severe emotional/mental stress, extreme physical exertion, coronary tortuosity, and connective tissue disorders.”³ 

Other risk factors are hormonal therapy, valsalva maneuvers (vomiting, coughing) as well as cocaine and amphetamine use.

Commonalities Between Migraine and SCAD

A study of 585 SCAD subjects found that 40% of people self-reported a migraine diagnosis and 26% of respondents reported migraine within the last year.³ “SCAD patients with migraine are younger at the time of SCAD; have more aneurysms, pseudo-aneurysms, and dissections among those imaged; and more often report a history of depression and post-SCAD chest pain.³ Also, women are more likely to be affected by SCAD with up to 80% being women.¹ Women are also three times more likely to be diagnosed with migraine compared to men. 

Fibromuscular dysplasia (FMD) is a disease that affects the arteries and causes narrowing, beading, bulging (aneurysm) and dissections in the medium to large arteries in the body. A study found 58% of those with SCAD had FMD and it has been reported in up to 30% of those with migraine.³ Genes such as PHACTR1 have also been associated with FMD and migraine.³

Pregnancy, Migraine and SCAD

SCAD is more likely to occur in the last trimester of pregnancy or during the postpartum period and is the most common cause of pregnancy related heart attacks. The stress of childbirth can result in SCAD through an unknown etiology. Hormonal therapy can also increase the incidence of SCAD for unknown reasons.⁵ 

Similarly, some women may experience migraine for the first time during pregnancy. For those that already live with migraine, many people find that during the first trimester headache attacks often worsen compared to the second and third trimester where migraine may be reduced or resolved. In the postpartum period, migraine worsens again for many. Both conditions may worsen or spontaneously develop during the postpartum period, inferring hormonal imbalances may be an underlying factor between the two. In migraine, the abrupt fall of estrogen is believed to be the primary trigger of headaches when they occur during or prior to menstruation.

What is the Connection Between Migraine and SCAD?

The associations between SCAD and migraine are unknown but may be related to vascular abnormalities, hormonal fluctuations, mood disorders and endothelial dysfunction. The underlying physiologies among both conditions are unknown. Although those with certain types of migraine have an increased risk of heart attack and stroke, it is unclear if migraine can predispose someone to SCAD.

SCAD Treatments

Conservative Therapy for SCAD: Most SCAD patients don’t need surgery to repair the dissection and instead the artery usually heals on its own. They may be placed on a medication regimen which typically includes beta blockers such as propranolol and a blood thinning medication such as aspirin. A study reported that treatment with beta blockers during the SCAD event had a lower incidence of recurrence compared to those who were not treated with beta blockers.⁶ 

Migraine Treatments That May Be Avoided With SCAD

Triptans and ergot alkaloids are commonly prescribed as abortive medications for migraine and may be discontinued in those who are diagnosed with SCAD due to vasoconstrictive effects. NSAIDS are also utilized as an abortive medication for migraine but may be avoided if the SCAD survivor is prescribed aspirin. Both NSAIDS and aspirin can thin the blood, therefore concurrent use can be dangerous. 

Migraine Treatments That Are Generally Safe With SCAD 

There are no known contraindications for the use of neuromodulation devices in people with migraine and SCAD. Gepants may be a safe option for these patients because they do not have a vasoconstriction effect. Also, Sphenopalatine Ganglion or occipital nerve blocks may be used as abortive or preventive migraine treatments, especially during pregnancy. Always talk to your doctor about which treatments are right for you.

A SCAD Treatment That May Be Avoided With Migraine

Nitrates, a class of drugs that treat high blood pressure and chest pain, may be prescribed after SCAD but may be avoided in those with migraine because severe headaches are a common side effect.

***** Prior to starting or stopping any medication, please consult with your doctor. This is not personal medical advice*****

Surgical treatment for SCAD: Depending on the patient and severity of the SCAD event, percutaneous coronary intervention (PCI) or cardiac bypass surgery may be performed. Percutaneous coronary intervention uses a catheter and stent to open the narrowed artery. This procedure is risky in SCAD patients because the artery can tear even more or the stent can be placed in the false lumen. Cardiac bypass surgery is reserved for patients who are extremely sick with multiple dissections or a large dissection and are hemodynamically unstable. This procedure takes a blood vessel from another part of the body (most often the leg) and connects it above and below the blocked artery to redirect blood flow. 

Generally, all post-SCAD patients should be referred to cardiac rehab.

What Type of Clinician Should I See for Migraine and SCAD? 

A cardiologist is the best type of doctor to see for SCAD. Migraine is best treated by a clinician that specializes in headache medicine. Interdisciplinary collaboration between both specialities can lead to the best treatment for both conditions.

A Note To Patients and Providers

Although SCAD is a rare cardiovascular condition, migraine is not. There are many overlapping comorbidities between SCAD and migraine such as Ehler-Danlos Syndrome, depression, fibromuscular dysplasia, anxiety, stroke and myocardial infarction. Neurologists and cardiologists should be aware which medications are recommended for both conditions and which may be best to avoid. Cardiologists should ask patients if they have migraine upon diagnosis and refer to a headache specialist as appropriate. People living with migraine should inform their provider if they have a history of SCAD. More research is needed for SCAD, therefore those with the condition are encouraged to enroll in clinical trials by routinely checking clinicaltrials.gov. The SCAD Alliance also has a registry known as iSCAD to advance research. More information regarding the registry can be found here. 

Allied Partner

Additional Resources 

1. SCAD Education
2. Coping with SCAD
3. Get Involved with Research
4. SCAD Support
5. SCAD Publications 
6. SCAD Research, Inc
7. SCAD Research Run/Walks

References

1. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2770944
2. https://www.scadalliance.org/what-is-scad/
3. https://www.ahajournals.org/doi/10.1161/JAHA.118.010140
4. https://www.jacc.org/doi/10.1016/S0735-1097%2821%2903794-3
5. https://www.jacc.org/doi/10.1016/S0735-1097%2819%2930641-2
6. YouTube video

*The contents of this blog are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The writer does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.