Experiencing migraine headaches can be challenging and painful. A subgroup of people who have migraine attacks experience migraine with aura, which involves experiencing distinct symptoms before or while the headache is occurring.
One recent study published in Neurology Open Access, an official American Academy of Neurology journal, evaluated how migraine was linked to risk for ischemic stroke in older and middle-aged adults. Ischemic strokes happen when there’s an obstruction of blood supply to the brain, and most strokes are of this kind.
The researchers found that experiencing migraine aura was linked to a higher risk of ischemic stroke.
When considering age and sex, researchers found there was also a higher risk for ischemic stroke for men under 72 who experienced migraine episodes with or without aura.
Previous research has suggested that migraine with aura may increase risk for ischemic stroke, but there has been less focus on middle-aged and older adults.
This research included 11,381 participants who were part of the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study, a group that included adults who were at least 45 years old. Participants provided answers via a phone interview regarding migraine headaches and experiencing migraine with aura.
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The average age of participants was just over 72 years old, and just under 10% of participants experienced migraine attacks. The average follow-up time with participants was 6.4 years.
Among participants with migraine, 3.9% experienced an ischemic stroke. This included 4.7% of migraine participants who experienced migraine with aura, and 3.3% of migraine participants who did not experience an aura. Among participants without migraine, 3.4% experienced an ischemic stroke.
Overall, researchers did not find that migraine in general was significantly associated with risk for ischemic stroke. Breaking this down by subtype, migraine without aura was not associated with a higher risk for ischemic stroke. However, migraine with aura was associated with a higher risk of ischemic stroke.
Exploratory analyses further found that men younger than 72 who had migraine episodes had the greatest risk for ischemic stroke. In contrast, women and older men did not appear to be at an increased risk for ischemic stroke.
Finally, while it didn’t reach statistical significance, participants with migraine were more likely to experience an ischemic stroke that was because of small vessel disease.
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Overall, researchers suggest their findings indicate that middle-aged and older adults who experience migraine with aura have a 1.5 to 1.9 times higher risk for ischemic stroke.
The study provides key insight into how migraine relates to stroke risk in older and middle-aged adults.
Walavan Sivakumar, MD, board-certified neurosurgeon, director of neurosurgery, and chief of staff at Providence Little Company of Mary in Torrance, CA, who was not involved in this research, offered Medical News Today his perspective on the study findings.
Sivakumar noted that:
“The REGARDS cohort is a robust, biracial national sample with rigorous stroke adjudication, lending credibility to the findings. The headline result — that migraine with aura confers a 73% increased hazard of ischemic stroke even after adjusting for traditional cardiovascular risk factors — is clinically meaningful. What I found most striking, however, was the unexpected subgroup finding: Men under 72 with migraine, regardless of aura status, had more than a 3.5-fold increased stroke risk, which was counterintuitive given prior literature emphasizing risk in younger women. That finding alone warrants serious follow-up.”
While these study results are insightful, they also have limitations. For example, there may be a risk for bias related to the exclusion of younger women with migraine who had already experienced a stroke.
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Researchers encourage caution when it comes to the stroke subtype information in this study since they had limited data on this front.
Some data, like migraine status, sex, and race, were based on participant reporting. Additionally, clinical care access may not have been equal for participants, and it’s possible that there was some migraine misclassification that occurred. Misclassification could have led to lower associations regarding migraine and ischemic stroke.
Migraine with aura was also self-reported, based on participants reporting vision changes prior to migraine headaches.
Since blurry vision can also occur with migraine headaches, it’s possible that there was overclassification when it came to migraine with aura status. Based on how aura was evaluated, non-visual auras were also not evaluated.
Researchers didn’t have data on when participants were diagnosed with migraine, which also could have impacted findings. Residual confounding is also possible because of unaccounted-for factors.
Since the study population only included white and Black individuals, it’s unclear if the results would be similar in other groups. The research may also be limited by other components of the REGARDS study.
For example, researchers note that this study “oversampled Black adults and individuals living in the southeastern Stroke Belt area of the United States.” Finally, funding of the study and the related guidance could have influenced results.
Reza Bavarsad Shahripour, MD, RPNI, FASN, FAHA,Assistant Professor in the UCSD Stroke Center, and Director of the Neurovascular Lab in Department of Neuroscience at UCSD, who was likewise not involved in this research, highlighted the following limitations of the data:
“Migraine diagnosis and aura status were based on self-report rather than formal International Headache Society diagnostic criteria, and the study lacked detailed information regarding migraine onset, attack frequency, severity, and treatment history. Additionally, although the relative risk increase was significant, the absolute event rates remained relatively modest, with ischemic stroke occurring in 4.7% of participants with migraine with aura compared with 3.4% of those without migraine.”
This research suggests that it may be important to consider migraine with aura when it comes to risk factors for ischemic stroke, although there’s likely a need for more research.
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Shahripour noted that, “from a clinical standpoint, these findings may encourage clinicians to incorporate migraine history, especially aura symptoms, into broader vascular risk assessment and stroke prevention counseling.“
“Migraine with aura may represent more than simply a headache disorder and could potentially serve as an independent cerebrovascular risk marker,” he added.
Sivakumar also noted similar clinical implications, saying that: “This study reinforces that migraine with aura should not be treated as merely a headache disorder — it is a cerebrovascular risk marker that deserves a place in our clinical risk stratification conversations.“
“Neurologists and primary care physicians should be asking about aura status in patients who report migraines and documenting it,“ he added.
“If the male-under-72 subgroup finding is replicated, it could have real implications for how we counsel this demographic about stroke prevention, including aggressive management of modifiable risk factors like hypertension, dyslipidemia, and smoking. It may also prompt consideration of whether migraine history should be formally incorporated into cardiovascular risk scoring tools,” Sivakumar suggested.
