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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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NuvaRing for Menstrual Migraine: Blood Clot Risk?

Since starting the NuvaRing to manage menstrually associated migraine attacks four years ago, I’ve recommended it to numerous women who have migraine without aura. The NuvaRing is more effective than birth control pills because it provides a steady dose of hormones, while hormone levels still fluctuate throughout the day with the pill. But recent reports have raised questions about NuvaRing’s safety.

All hormonal birth control raises a woman’s risk of blood clots, but there is speculation that NuvaRing users are at greater risk than those who use oral contraceptives. Merck’s agreement to pay a $100 million settlement for thousands of liability lawsuits, announced on Friday, looks rather suspicious.

There are three studies that come into play when considering this risk. NPR summarizes them as:

“One funded by Merck, published in the journal Obstetrics and Gynecology in October, and another funded by the FDA, with data from Kaiser Permanente and Medicaid databases. The former found a similar risk for the ring and combined oral contraceptive pills. The latter found no difference in risk between new users of low-dose combined hormonal contraceptives and the NuvaRing or the birth control patch. (There was a higher risk found with pills that contain drospirenone, which is found in the pill Yaz.)

“But a study from Denmark, published in the British Medical Journal in May 2012, found a notably higher risk of blood clots from NuvaRing. Women using the NuvaRing were about six times more likely to get venous thrombosis than women who didn’t use any form of hormonal contraceptive. Compared to combined oral contraceptives with levonorgestrel, NuvaRing users were about twice as likely to form blood clots.”

Findings from the Danish study are not included in NuvaRing’s U.S. “label” (that’s FDA-speak for the detailed information that’s included with prescriptions). Again from NPR:

“FDA spokeswoman Andrea Fischer told Shots in an email that the agency ‘questioned the design and study population, and did not have the opportunity to independently review the original data.’

“For one thing, the study compares ‘all users,’ rather than just new users. ‘When using any hormonal contraceptive, the risk of blood clots is higher during the first few months of use,’ according to Fischer, so including both new and longtime users in the same study may make it seem like newer contraceptives are riskier, when actually new users of any method are already at a higher risk.”

The new versus all users distinction eased my mind considerably, though it still seemed kind of scary. The rest of NPR’s detailed explanation of the risks calmed me considerably. It’s too much to post here — it’s the entire second half of the long article — but take a look at Birth Control and Blood Clots: Women Still Weighing the Risk if you’re curious or concerned.

Personally, I’m going to continue using it for now. The risk just isn’t that great and I’ve already been on it for four years — if I were going to have problems with it, they probably would have shown up by now.

Still, since I’m older than 35 (the age at which women are warned to stop using hormonal birth control) and my migraines are no longer as constant or as devastating as they were when I started using the NuvaRing, I’ll probably go off it in a few months to see how I do without it. When I started hormonal birth control to manage menstrually associated migraine attacks, triptans were completely ineffective for me. Now that triptans are a viable option, they may ultimately be a better choice than hormonal birth control.

As with any medication, ask your doctor what your individual risk is given your own medical history and what your other treatment options are. With that information in mind, consider how much risk you’re OK with — a minute risk is acceptable for some women, for others any risk is a deal-breaker.

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Maybe Birth Control Pills Would Be OK

Talking to Hart about hormonal birth control, migraine and stroke risk got me wondering what my risk really is. If it is low, multiplying the number by eight isn’t that big of a deal. Kersti explains this well in her comment on the post:

[T]he problem with statistics is that they’re misleading. 8 times more likely… 8 times what? You need to find out what the baseline actually is, and you need to find it out for your own ethnicity, gender, circumstances before you know if this is a problem. If for example the baseline is 10% then 8 times is pretty ghastly, however, if the baseline is 0.01% then you’re still at 8 times 99.92% likely to NOT get one.

I’m kind of embarrassed I didn’t think this through before I wrote the post. I’m always urging readers to think critically. No matter how much I recommend caution, I too fall into the trap of fear. “Stroke? Eight times more likely? No way!” is how I reacted yesterday.

According to the American Heart Association’s stroke risk factors, I’m at very little risk. That’s reassuring. I’ll talk with the doctor on Monday and see what she recommends.

Check out the this BBC article on understanding — and critically evaluating — statistics, which Kersti suggested.

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Migraine Linked to Blood Clots in Veins

People with migraine may be more likely to develop blood clots in their veins than those without, according to a study published today. Called venous thrombosis or thromboembolism, the blood clots can lead to strokes. Researchers speculate this is why people with migraine have a greater risk of stroke.

Studies of stroke and migraine implicate only people who have visual auras with their migraines. I wonder what migraine types the blood clot study participants had.

From Science Daily:

Of the [574] participants, 111 people had migraine. A total of 21 people with migraine also had one or more instances of venous thrombosis, or 19 percent. In comparison, 35 people without migraine had the condition, or 8 percent.

Researchers do not know why migraine and venous thrombosis are linked. One theory is that the blood of people with migraine may be more prone to clotting.

The study also found that people with migraine are not more likely to have hardening or narrowing of the arteries, which is contrary to a current theory.

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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.