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Migraine and Stroke, Heart Disease: Understanding the Risks

Learning that research has found connections between migraine and stroke and heart disease can be chilling. Fortunately, the news is not as bad as it might first appear. I spoke with headache specialist Gretchen Tietjen, M.D., about an article on the connection between migraine and an increased risk of stroke and cardiovascular disease that she wrote for the American Migraine Foundation. “From a patient’s perspective, this information is frightening,” I told her (because I have no poker face, even on the telephone). Dr. Tietjen soothed my worries tremendously by putting the information into perspective.

“It can be very scary when you read things like this,” Dr. Tietjen said. “Study after study shows this little bit of increase.” However, the risk is very small. The most important takeaway is that patients should keep migraine in mind as part of their overall risk for stroke and heart disease. If you have migraine and are at increased risk of stroke or heart disease, it’s extra important to be aware of and manage those risk factors.

Migraine Increases the Risk of Stroke and Cardiovascular Diesease (But Only a Little Bit)

Yes, migraine does increase the risk of stroke, particularly for women who have migraine with aura. But the risk is very, very small. Less than 1% of all strokes in women have any connection to migraine. And the presence of a connection is not proof of a causal relationship—that is, just because the two are linked doesn’t mean that migraine causes stroke.

The article reports that a recent study found “that migraine increases the risk of stroke, coronary events, and related death by about 50%.” At first glance, that sounds terrifying, but Dr. Tietjen’s clarification was soothing. She said, “This sounds worrisome but to put this in perspective only 1% of the total population in the study had a cardiovascular event over the 20 years of follow-up. The take home message is that having migraine does not mean you will have heart disease or a stroke, only that it appears to slightly increase the risk.”

Risk Factors For Stroke and Heart Disease

Dr. Tietjen highlighted risk factors like smoking, high blood pressure, high cholesterol, and diabetes. She said that in people with migraine, these factors have an additive effect—the combination of more than one risk factor is worse than any one by itself. If you have any of these risk factors in addition to migraine, quitting smoking, lowering your blood pressure and/or cholesterol, or getting your diabetes under control could lower your risk of heart disease substantially. Smoking is the risk factor that stands out the most to Dr. Tietjen. Studies of migraine and smoking have shown that the combination of the two increases your stroke and heart disease risk more than either one on it’s own.

Learn More About Migraine, Stroke and Heart Disease

Dr. Tietjen’s article, Migraine, Stroke and Heart Disease has in-depth information on who is at increased risk of stroke, differentiating between symptoms of migraine and stroke, the physiological links between migraine and stroke, and ways to lower your risk. As you read the article, keep in mind that the absolute risk is small and that you can modify your risk factors for stroke and heart disease. And make a list of any questions you may have so you can ask your doctor at your next appointment.

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Migraine & Headache News From the American Academy of Neurology’s Annual Meeting

Migraine-related study findings presented at the American Academy of Neurology’s annual meeting, April 12-19.

Migraine Increases Risk of Severe Skin Sensitivity and Pain
The study found that 68 percent of those who reported almost daily headaches (chronic migraine) and 63 percent of those with episodic migraines reported allodynia, the name of this intensified and unpleasant, painful skin sensitivity. Forty-two percent of people with probable migraine reported the skin pain compared to 37 percent of those with daily or tension headache.

Migraine Frequency Linked with Women’s Risk of Cardiovascular Disease
New research shows women who have weekly migraine are significantly more likely to have a stroke than those with fewer migraines or no migraine at all, but those with lower migraine frequency may face increased risk of heart attacks.

Breastfeeding While Taking Seizure Medicine Does Not Appear to Harm Children
A first of its kind study finds breastfeeding while taking certain seizure medications does not appear to harm a child’s cognitive development.

Children with Migraine at Increased Risk of Sleep Disturbances
Children with migraine are more likely to have sleep disorders, such as sleep apnea and lack of sleep, than children without migraine, according to research on the effects of headaches on children’s sleep patterns.

Overuse of Codeine, Oxycodone and Barbiturates Increases Risk of Chronic Migraine
People who overuse barbiturates and opioids, such as codeine, butalbital, and oxycodone, to treat migraine are at an increased risk of developing chronic migraine.

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Migraines During Pregnancy Linked to Heart Disease & Stroke

Women who have migraines during pregnancy have a greater risk of stroke or heart disease than pregnant women who don’t. Using pregnancy discharge data from nearly 17 million women in the US, researchers found that almost 34,000 women had been treated for migraines. These women were 19 times
more likely to suffer a stroke, five times more likely to have a heart
attack and more than twice as likely to have heart disease, blood clots
and other vascular problems.

The study uncovered a possible link, not proof that having migraines directly causes stroke or heart disease. As with nearly every study on migraine and other headache disorders, it establishes that people with one disorder are more likely than the general population to have another (often referred to as comorbidity), not cause and effect. It’s just enough to open up further research on the subject.

Articles on this study recommend prevention over treating migraines as they occur. Headache specialist Richard Lipton makes a point that everyone with headache should consider.

“People with migraine should view migraine the same way they would view diabetes or high cholesterol, as a medical problem that should be managed to make life better today and prevent complications tomorrow. Rather than being alarmed, people with migraine should get the migraines treated and make sure they modify risk factors for heart disease and stroke by maintaining a normal body weight and treating high blood pressure.”

The slew of not-so-good news of late is tempered by good news about migraine and memory. It is also a reminder to pay attention to your health as a whole, not just your headaches or migraines. I’m getting better at this, particularly in my diet, but it’s impossible to avoid all the risk factors for any illness. I figure that everything I do or encounter can possibly kill me, so I do the best I can without freaking out.

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A Headache Specialist’s Comments

Christina Peterson, a neurologist (and migraineur), is a blog reader who leaves terrific, educational comments. I always learn a lot from her. Some of her comments on recent posts are so informative that I want to be sure you all see them.

Warnings Proposed for OTC Painkillers

This is a really important post–it can’t be overstated.

In fact, the NYT article, if anything, understates the matter. The truth is that at this time, over 50% of all liver transplants are necessary because of the medical use of acetaminophen. It’s such a big problem that even the makers of Tylenol have run a commercial asking people not to exceed the recommended amount.

Gastritis and ulcers are no fun, and most people have been made aware of the cardiac and blood clot risks of anti-inflammatories like Vioxx and Celebrex, but a lot of people tend to think that ibuprofen and acetaminophen are benign.

They aren’t.

It’s also important to know that a lot of prescription analgesics, like Vicodin, Percocet, Fioricet, Amidrin (and all their generic names), also contain acetaminophen–so don’t double up.

If you are an intermittent migraine sufferer, and not a chronic headache sufferer, a double-blind randomized controlled trial has established that acetaminophen has no role in the treatment of acute migraine. There are better options available.

Men & Women Experience Pain Differently

This is vastly oversimplified. (Well, OK, it’s a newspaper…) But I trust this blog readership to be more sophisticated than the sixth grade level general readership a newspaper shoots for. So.

Most of the studies that have recently emerged have indeed shown a difference in pain processing between men and women. The major difference is that pain processing in women fluctuates with estrogen levels. (Estrogen–it’s our theme of the week, isn’t it? 🙂

Some of the studies available are simplistic and misleading–lab animals were injected with estrogen, and pain thresholds decreased, which led researchers to conclude that therefore, women were weak, and couldn’t tolerate pain as well as men. (Can anyone say, “Researcher bias”?)

But if you think this through, it is counter-intuitive. It makes no sense. Pregnant women have very high estrogen levels–estrogen levels climb throughout pregnancy, until they are very high by the time labor begins.

And menstrually-associated headaches occur when estrogen levels are at their lowest–the day before menstruation begins is the most common day for a menstrual migraine, and that is the day for a drop in estrogen.

Dr. Nancy E.J. Berman, who has done very important research on the effects of hormones on trigeminal neurons and the effects on orofacial pain, TMD, migraine and fibromyalgia, and who won the Wolff Award this year from the American Headache Society, also wrote the chapter on “Sex Hormones” in the book, The Headaches. She has noted that migraine improves both during pregnancy, when estrogen is high, and after menopause, when estrogen is low. She feels that this suggests that it is rapid changes in estrogen and progesterone that serve as a trigger for migraine attacks.

Some studies suggest that women tolerate pain better than men when estrogen levels are higher, and less well than men when estrogen levels drop–we are still discovering whether it is the rate of drop that is critical (likely), or whether it is also the estrogen:progesterone ratio that has an effect.

Other studies have shown that postmenopausal women process pain similarly to men.

I will say this, though: when I do Botox injections in the office, it’s generally not the women who get faint on me. 😉

Birth Control Pill News

This is all well and good…if you are young, and if you do not have migraine with aura.

Please refer to the following from the ACHE website: Will Using Oral Contraceptives Increase the Risk of Stroke?

It is the standard of care amongst headache experts to advise that women with migraine with aura either not use oral contraceptives at all, or use them very judiciously and with aspirin cardiac prophylaxis, and only if there are no significant cardiovascular risk factors. It is also recommended that women who have migraine without aura discontinue oral contraceptives after age 35. Smokers who have migraine should not use oral contraceptives at all.

I recall reading a recent article that surveyed migraine sufferers, and found that a significant proportion of primary care physicians were not aware of current recommendations regarding migraine and oral contraceptives. (I cannot, however, find the article in my giant stack-of-articles-to-be-filed. So, no citation for you–sorry. I think the author was Dr. Elizabeth Loder, but Google is not bringing it up.)

There is also newer data regarding the increased risk of heart disease in women with migraine, which was published in JAMA recently.

This study looked at women over 45, but estrogens, contained in the vast majority of contraceptives, are also a cardiac risk factor.

So–if you are going to proceed with this, be certain your physician knows you are a migraine sufferer (if you are), and research your family history and personal cardiovascular risk factors.

To learn more about and from Dr. Peterson, visit her websites, Migraine Survival and Headquarters Migraine Management.