Fatal stroke in migraine: a case report with autopsy findings

Lipoprotein a levels in pediatric migraine

The purpose of this study was to examine the lipoprotein (a) [Lp(a)] levels in children with migraine to see a possible relationship between migraine and stroke via high Lp(a) levels. Plasma levels of Lp(a) were determined in 63 patients and age-matched control subjects. The mean age in the control group was 10.57 ± 3.63 years and 11.51 ± 3.19 years in the migraine patient group. The mean Lp(a) levels in control group were 10.36 ± 10.41 ng/mL and 17.09 ± 12.12 ng/mL in migraine group (P < 0.05). The median Lp(a) level in the control group was 49.38 ng/mL and was 77.62 ng/mL in the migraine group (P < 0.05). Twelve patients (19%) had Lp(a) levels of >30 ng/mL in the migraine group and 4 (6.3%) in the control group (P < 0.05). Several prothrombotic factors related to an increased risk of stroke have been studied in migraine patients. It has recently been reported that high Lp(a) concentrations represent a risk factor for migraine, thus establishing a novel plausible link between migraine and stroke. The current study suggests evidence of high Lp(a) concentrations in childhood migraine; perhaps a novel link exists between migraine and stroke.

The risk of stroke in patients with migraine and implications for migraine management

Assessing the risk of stroke in persons with migraine is complicated by the intricate relationship between these two conditions. Both migraine and stroke are common and co-morbidity may, in some cases, be coincidental. Given the overlap of clinical symptoms in stroke and migraine, each condition may also mimic the other. Numerous studies have, however, shown that migraine is an independent risk factor for stroke both during, and remote from, the migraine attack. Women of childbearing age and those with aura are at greatest risk of migraine-related stroke. Additional risk of stroke in migraineurs occurs in those using oral contraceptive pills and who smoke cigarettes. Elevated blood pressure, an important stroke risk factor, is less common in migraineurs. Acquired antiphospholipid antibodies, not clearly a cause of migraine per se, may raise the risk of infarction in migraineurs. Hereditary conditions, including CADASIL (cerebral autosomal dominant arteriopathy with sub-cortical infarcts and leukoencephalopathy), MELAS (mitochondrial myopathy, encephalopathy, lactacidosis and stroke) and hereditary haemorrhagic telangiectasia, appear to predispose to both migraine and stroke. Purported mechanisms for migraine-associated stroke include involvement of the vasculature (including vasospasm, arterial dissection and small vessel arteriopathy), hypercoagulability (elevated von Willebrand Factor, platelet activation) and elevated risk of cardioembolism (patent foramen ovale, atrial septal aneurysm). Triptans and ergotamines, used to treat acute migraine attacks, appear to be safe in low-risk populations. These medications should be avoided in persons with haemiplegic migraine, basilar migraine, vascular risk factor and prior cerebral or cardiac ischaemia.

[Roles of arterial dysplasia, chronic ergotism and other factors in a case multiple spontaneous arterial dissections]

INTRODUCTION

Spontaneous dissection of cervical and visceral arteries are rare and usually associated with an underlying arterial disease.

EXEGESIS

The authors report the unusual case of a 50-year-old woman with high blood pressure who presented spontaneous dissection of cervico-cephalic, renal and hepatic arteries and of the descending aorta. She had been taking ergotamine tartrate for ten years for migraine. She also suffered from Raynaud's syndrome worsened by treatment.

CONCLUSION

The respective roles of arterial dysplasia, chronic ergotism, renovascular hypertension and migraine are discussed.

Migraine and stroke in childhood and adolescence

Over 3 years we evaluated two patients, an adolescent and a child, with migraine-like headache and ischemic stroke. Based on our clinical observations and on literature review of migraine and stroke in the pediatric age group, we believe that the criteria of migrainous infarction outlined by the International Headache Society (IHS) could be occasionally too restrictive. Therefore, we suggest subclassifying migrainous infarction into: (i) "definite", referring to the patients whose ischemic stroke fulfills all the IHS criteria, (ii) "possible", referring to ischemic strokes which fulfill some, but not all, criteria. This subclassification of migrainous infarction may be relevant in clinical practice and in human research studies.

Fatal cerebellar infarction in a migraine sufferer whilst receiving sumatriptan

This is a case report of a 39-year-old man who suffered from a fatal cerebellar infarction whilst on sumatriptan therapy for an acute attack of migraine. Intracranial vasospasm is proposed as the likely causative mechanism and possible therapeutic intervention is highlighted.