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Abstract

Migraine is a common chronic disorder, especially amongst women – approximately 18% of US women will have had a migraine attack within the past year. Cardiovascular disease is the biggest killer in the same population. This review summarizes the best available epidemiological evidence for an independent association between migraine and cardiovascular disease amongst women. The most reliable evidence comes from the Women's Health Study, which found that migraine with aura raised the risk of ischemic stroke by 91% (95% CI: 17–210%) and myocardial infaction by 108% (95% CI: 30–231%). Migraine without aura raised both risks by approximately 25%. The other prospective studies that were identified gave broadly supportive results, and suggested that the risks from migraine were attenuated with age. It would be prudent for women who suffer migraine with aura to seek medical advice and consider lifestyle changes in order to improve their cardiovascular risk profile.

Keywords

coronary heart disease ischemic stroke migraine myocardial infarction

Cardiovascular disease (CVD) is the leading cause of death amongst women in the USA and many other countries. Although the major causes of CVD are well established, the current tools for predicting whether any particular woman will go on to develop CVD are imperfect, leaving the question of what else needs to be accounted for when deciding upon suitable preventive lifestyle and medication interventions? For some years it has been theorized that migraine may be one such ‘unaccounted’ risk factor, although this is still the subject of current research [1]. This review discusses the epidemiology of migraine in the USA and summarizes the best epidemiological evidence available regarding a potential association between migraine and either coronary heart disease (CHD) and/or stroke, as far as this relates to women.

Epidemiology of migraine

Migraine is a chronic neurological disorder, defined by the International Headache Society as a recurrent headache disorder manifesting in attacks lasting 4–72 h, with typical characteristics of the headache being unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia [101]. Three national surveys in the USA (1989, 1999 and 2004) have shown that the prevalence of migraine in the USA has remained stable in recent years, with approximately 18% of women having suffered from a migraine in the past year and three in four migraineurs being female [2]. The median age at onset of migraine for women is 25.2 years [3], but migraine prevalence peaks (at ~27%) at age 40 years [4] – in all, migraine is most prevalent in the most productive years of female lives. Furthermore, 43% of women will contract migraine during their lifetime [3].

The factors that initiate migraine, in general, are poorly understood, although any specific sufferer may have her own trigger. Known triggers include glare, heat, motion, noise, hunger, odors, alcohol, certain foods, stress, anxiety and sleep deprivation. In addition, migraine is strongly influenced by female hormones [5].

Approximately 15–20% of migraineurs have migraine with aura [101]. Although nonvisual auras are not unusual, 99% of those who have migraines with aura experience a visual aura in some, or all, of their attacks. The most common auras are visual scintillating scotoma, circumscribed by shimmering lights [6]. The epidemiology of migraine with and without aura may differ, insofar as the causes and sequalae may not be the same. However, whether epidemiological studies, which typically use self-reported information, will always successfully differentiate aura from no aura is debatable.

Cardiovascular risk factors in migraineurs & nonmigraineurs

The Women's Health Study (WHS) has published data on the relationships between migraine and CVD risk factors amongst over 27,000 US health professionals, free of CVD and cancer, aged 45 years and older [1,7]. They compared three groups of migraineurs (active – in the last 12 months – with aura; active without aura; and past migraine sufferers) with those without any migraine history (controls). Overall, migraineurs were found to have higher total cholesterol, low density lipoprotein-cholesterol, Apo-B, ICAM-1 and C-reactive protein, and lower high density lipoprotein (HDL)-cholesterol than controls. Migraineurs were also more likely to be hypertensive (although not to have a higher mean blood pressure) and less likely to take any regular exercise. There were inconsistent relationships between the three migraine groups and BMI – only those with aura had a lower mean BMI than controls; smoking – only those with past migraine were more likely to be current smokers and to have ever smoked, compared with controls; and age – only those with past migraine were, on average, older than controls. Those with active migraine with aura generally had a worse cardiovascular profile than those with active migraine without aura. However, none of the differences found were large, whilst generalizability of the results is problematic owing to the healthy status of the WHS study population. Furthermore, the published analyses seem to make no allowance for skewed distributions, which affect both the appropriate estimate of average and the tests of significance reported by the WHS [8].

Other literature (not necessarily restricted to women) supports the associations between migraine and both smoking and hypertension [9], and both total and HDL-cholesterol [10], found by the WHS. The Kaiser-Permanente study found an additional difference amongst its female subpopulation; those with migraine had less formal education than those without [9]. Migraineurs are more likely to have used oral contraceptives (OCs) [10 –13] and hormone therapy (HT) [11 –13], both of which may have a relationship with the risk of CVD. Since migraine may thus be coincident with established or purported CVD risk factors, it is important to adjust for these when determining the association between migraine and CVD [8].

Migraine & coronary heart disease

Reliable epidemiological data concerning the potential causal relationship between migraine and CHD, or myocardial infarction (MI), are scarce. Leaving aside data from cross-sectional surveys, which are unreliable for investigating causality [8], there are currently six studies [9,11,12,14–16] that provide a basis for quantifying the relationship amongst either women or women and men combined ( Table 1 ). All of these are prospective studies (here defined as studies where migraine status is related to succeeding events) and four [9,11,14,15] gave distinct results for women. However, the earliest of the studies [14] only provided unadjusted rates of death from CHD (and stroke), gave no measure of variation for the association between migraine and CHD, used a nonspecific measure of migraine and had relatively small numbers, and so will not be mentioned further.

Table 1.

Prospective studies of coronary heart disease/myocardial infarction and ischemic stroke amongst women, and amongst women and men combined. Relative risks are adjusted for multiple confounding factors except where stated.

Study	Age (years); sex	Country; follow-up (years)	Relative risk (95% CI)		Ref.
Study	Age (years); sex	Country; follow-up (years)	CHD/MI	Ischemic stroke
Women's Health Study Kurth et al. (2006)	≥ 45; women	USA; 10	2.08 (1.30–3.31) with aura (Ml) 1.22 (0.73–2.05) without aura (Ml)	1.91 (1.17–3.10) with aura 1.27 (0.77–2.09) without aura	[11]
Kaiser-Permanente Sternfeld et al. (1995)	Mean 39; women	USA; 14–16	1.37 (0.80–2.36) (Ml)	–	[9]
GPRD Nightingale et al. (2004)	15–49; women	UK; ≤7	–	2.33 (1.04–5.21)	[23]
Rhondda Valley Waters et al. (1983)	20–64; women	UK; 12	0.67* (CHD)	0.67*	[14]
ARIC Rose et al. (2004); Stang et al. (2005)	45–64; women and men‡	USA; 4–9‡	1.1 (0.5–2.2) with aura (CHD) 1.3 (0.8–2.2) without aura (CHD)	2.07 (0.96–4.44) with aura 0.86 (0.37–2.00) without aura	[15] [24]
GPRD Hall et al. (2004)	All ages; women and men	UK; 3	1.29 (1.15–1.44) (CHD) 1.15 (0.96–1.38) (Ml)	2.49 (1.62–3.83)	[16]
United Healthcare Velentgas et al. (2004)	Median 39; women and men	USA; ≤5	0.96 (0.80–1.15) (Ml)	1.67 (1.31–2.13)§	[12]

Unadjusted.

‡

CHD results shown for women only (maximum of 7 years follow-up).

AII types of strokes included.

ARIC: Atherosclerosis Risk in Communities; CHD: Coronary heart disease; GPRD: General Practice Research Database; Ml: Myocardial infarction.

The WHS reported results of an average 10 years follow-up of 27,840 women aged 45 years or older [11]. Of these, 3610 reported active migraine (1434 with aura) at baseline. Compared with those with no history of migraine, those with migraine with aura at baseline had a relative risk (RR) for MI of 2.08 (95% CI: 1.30–3.31), adjusted for a host of conventional CVD risk factors plus postmenopausal status, use of HT and history of OC use. Compared to the same reference group, those with active migraine without aura had a corresponding result of 1.22 (95% CI: 0.73–2.05). Survival curves [8] showed that the effect of migraine with aura only became apparent after 6 years of follow-up. Prior to this, survival, free from CHD, was very similar for women with migraine (with and without aura) and women with no history of migraine.

The Kaiser-Permanente study [9] followed up nearly 80,000 women and men, with results reported separately by sex and whether or not migraine was self-reported (active in the last 6 months) or reported by the subject's physician. Amongst 25,117 adult women in the ‘self-reported cohort’, 1911 (8%), with a mean age of 39 years (standard deviation, 13 years), reported having active migraine. Subjects were followed up for between 14 and 16 years, during which time there were 423 hospitalizations for MI. After adjusting for classical CVD risk factors, the RR for MI (comparing those with migraine to those without migraine) was 1.37 (95% CI: 0.80–2.36). No results were reported for the other female cohort taken in its entirety. However, for women in this second (‘physician reported’) cohort with no family history of MI, the adjusted RR for migraine versus no migraine was reported as 1.51 (95% CI: 0.88–2.39), which was compared with 2.4 (95% CI: 1.4–4.2) for women with a family history (the inconsistent rounding is as published). It may be that this subgroup analysis was reported purely because it happened to be the only one with a significant result in post hoc analyses.

Another study to report relevant results for both women and men was the Atherosclerosis Risk in Communities (ARIC) study [15]. Amongst 5591 women with no CHD at baseline, and whose CHD event did not precede her headache (whenever both occurred), the RR for CHD was 1.1 (95% CI: 0.5–2.2) for those with a history of migraine with rapid-onset aura, and 1.3 (95% CI: 0.8–2.2) for those without aura, each compared with women who reported no history of headaches lasting 4 h or more. These RRs were adjusted for major CVD risk factors plus income and race. Between ascertainment of headache histories and the termination of event recording, 4–7 years elapsed. The average age of study participants when their headache histories were recorded was 60 years.

Both the Kaiser-Permanente and ARIC studies suggested slightly lower RRs for men than women. Nevertheless, data from prospective epidemiological studies that include both women and men, or only encompass men, are also informative to this review and are worthy of mention given the small number of studies showing purely female data. A study of the General Practice Research Database (GPRD) in the UK by Hall et al. found 63,575 patients with at least one recent migraine attack, the majority of whom (approximately 47,000) were women [16]. Each was matched, for sex, age and primary care practice, with one or two controls (77,239 in total). After recording events over just less than 3 years, the RR for CHD, comparing migraine cases to controls was 1.29 (95% CI: 1.15–1.44), after adjustment for major CVD risk factors and OC use. The corresponding result for MI was 1.15 (95% CI: 0.96–1.38). A similar study of health insurance records in the USA found 130,411 members (76% of whom were women) with either a recent prescription or medical encounter consistent with migraine, and matched each to a single control by sex, age and health plan membership [12]. The median (first; third quartile) age of both cases and controls was 39 years (29 years; 48 years). After a maximum of 5 years follow-up, the RR for MI, migraineurs versus nonmigraineurs, was 0.96 (95% CI: 0.80–1.15), adjusted for age, sex, comorbidities, year at enrolment, OC and HT use, but not major CVD risk factors. Finally, the Physician's Health Study (PHS) followed-up 20,084 men aged 40–84 years, without CVD or angina, 1449 of whom had migraine in the last 5 years, for an average of almost 16 years [17]. Comparing those with such migraine history to those without, the RR for MI was 1.42 (95% CI: 1.15–1.77) after adjusting for a raft of CVD risk factors.

Of all these studies, the WHS seems to offer the best quality evidence because it has a large sample size with a long follow-up, it reports purely for women, includes extensive adjustment for potential confounding variables, uses a nonmigraineur control group and has a verified definition of migraine. The WHS suggests that a woman who currently has migraine with aura will have approximately twice the risk of MI compared with another woman with a similar conventional cardiovascular risk profile who has no history of migraine. Migraine without aura seems to have much less of an effect, only raising risk by 22%. This study also suggests that a follow-up period of at least 6 years is required to see any noticeable effects for women (the PHS demonstrated something similar for men [17]). Allowing for the expected prevalence ratio of approximately one person with migraine with aura to five without [101], the results from the WHS [11] are supported by both the Kaiser-Permanente study [9] and the PHS [17], each of which recorded incident MI over longer periods than the WHS. The other two studies that reported results for MI each had shorter average follow-ups [12,16], which may help explain their estimates of RR associated with migraine being near unity. The ARIC study reported CHD [15], rather than MI, with an overall result comparable to the RR for CHD reported by Hall et al. [16], of approximately 1.3. These studies suggest that the excess risk for overall CHD owing to migraine may be slightly smaller than that for MI. This is consistent with the lower RRs for angina ('soft’ CHD), compared with MI (‘hard’ CHD), reported by the WHS and PHS. However, ARIC reported much higher RRs for angina than for CHD. Some allowance must be made for the different reference group (those free of serious headaches) used by ARIC; other studies used nonmigraineurs as the reference.

Migraine & ischemic stroke

Migraine is identified as a risk factor for ischemic stroke in the American Heart Association (AHA)/American Stroke Association guidelines [18]. The decision to include migraine was made on the basis of both epidemiological evidence and the purported links between the mechanisms underlying the pathophysiology of migraine with aura and the risk of stroke [19]. One of the likely mechanisms is patent foramen ovale, an incomplete closure in the walls of the chambers of the heart, which is thought to cause blood clots to enter the arteries leading to the brain. This has been found to be related to both migraine and stroke [19,20], and can be treated by surgery [21].

A summary of the epidemiological evidence regarding the migraine–stroke relationship up to 2004 [22] reported a summary RR for ischemic stroke, migraineurs versus nonmigraineurs, across 14 studies, of 2.16 (95% CI: 1.89–2.48); the RR for migraine with aura (seven studies) was 2.27 (95% CI: 1.61–3.19); and for migraine without aura (6 studies) the RR was 1.83 (95% CI: 1.06–3.15). Unfortunately, all but three of the studies identified (none of which separated aura from no aura) were case–control studies, which are more susceptible to bias error than prospective studies [8]. At the time of writing, there are six prospective studies [11,12,14,16,23,24] that quantify the migraine–ischemic stroke relationship for either women or women and men combined ( Table 1 ). Three of these give distinct results for women [11,14,23], although (as with CHD) one of these [14] will be ignored here owing to the problems raised earlier. One further study includes men only [17].

Compared with women who have no history of migraine, those in the WHS with active migraine with aura had a RR of 1.91 (95% CI: 1.17–3.10) for ischemic stroke, after adjustment for conventional CVD risk factors, postmenopausal status, HT use and history of OC use; those with active migraine without aura had a corresponding result of 1.27 (95% CI: 0.77–2.09) [11]. As with CHD, there was little evidence of an effect of migraine status on subsequent stroke until 6 years had passed. The only other prospective study reporting results for women was a nested case–control study of female patients in the GPRD by Nightingale et al., which reported results for women aged 15–49 years, contrasting with the 45 years or older range of the WHS [23]. A total of 190 incident ischemic stroke cases were matched by 1129 controls for age and doctor. The RR for ischemic stroke, comparing those with migraine (defined according to a relevant prescription or diagnosis in the past 12 months) to those without was 2.33 (95% CI: 1.04–5.21), after adjusting for several CVD risk factors, including pre-existing CHD and venous thromboembolism, and reproductive status, including OC use.

As with CHD, the paucity of prospective data on the relationship between migraine and stroke for women leads to consideration of prospective studies of women and men combined [12,16,24] and men alone [17]. The study by Hall et al., based on the GPRD, reported a migraine–ischemic stroke RR of 2.49 (95% CI: 1.62–3.83), after adjustment for hypertension, diabetes, obesity, hypercholesterolemia, smoking and OC use [16]. Although this study used a different sampling method to the GPRD study by Nightingale et al. [23], they do not appear to be mutually independent. The health insurance study in the USA [12], also referred to earlier, reported a migraine–stroke RR of 1.67 (95% CI: 1.31–2.13). Although this study failed to distinguish types of stroke, most of the strokes observed are likely to have been ischemic. The ARIC study was another study included in the review of CHD that also reported on ischemic stroke, but this time in a separate publication [24]. Men and women with migraine with aura had a RR of 2.07 (95% CI: 0.96–4.44) for incident ischemic stroke, compared with those with no history of headaches; for migraine without aura this reduced to 0.86 (95% CI: 0.37–2.00). Finally, the PHS reported a migraine-ischemic stroke RR of 1.12 (95% CI: 0.84–1.50) amongst 40–84-year-old men [17].

In interpreting these overall estimates of RR from several studies it is important to consider the potential differences between age and sex groups. The WHS showed a decreasing trend in the RR for ischemic stroke due to migraine with aura, from 2.59 at ages 45–54 years to 2.13 at ages 55–64 years to 0.32 at ≥65 years – no such trend was observed for migraine without aura [1]. Further support for the hypothesis that the effect of migraine attenuates with age for women comes both from contrasting the results of the WHS with those of Nightingale et al. [23] and the statement by Hall et al. [16] that, amongst women, the strongest association between migraine and risk of ischemic stroke was found amongst those at child-bearing ages. Also, a large two-phase, cross-sectional study in the USA [13] reported estimated RRs for ischemic stroke, migraine versus no migraine, that decreased continuously with increasing at-risk age, from 2.81 at age 40 years to 1.69 at age 60 years to 1.16 at 90 years. From this evidence, it is reasonable to conclude that migraine has a decreasing effect with increasing age, in that it is a risk factor for ischemic stroke at ages below approximately 60 years old, but not at higher ages [18].

None of the prospective studies compare women with men, but the best evidence available, from case–control studies, suggests that the effect of migraine on ischemic stroke, at the ages when it has most effect, is slightly greater for women than men. The pooled RR (95% CI), migraine versus no migraine, from nine studies of women and men was 2.36 (95% CI: 1.92–2.90), compared with 2.76 (95% CI: 2.17–3.52) from seven studies amongst women only [22]. Another point to highlight is the much lower RR found in the PHS [17] compared with the two RRs shown in Table 1 from the WHS [11]. The US guidelines state that ‘migraine headache has been most consistently associated with stroke in young women’ [18].

Case–control studies also suggest that OC use [22] and smoking both amplify the effect of migraine on ischemic stroke amongst young women, for example, in the WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception [25] and the Stroke Prevention in Young Women Study [26]. However, the WHS did not find such an effect for smoking [1] and Nightingale et al. found no evidence of interaction between migraine and reproductive status (including OC use) [23]. The best evidence to hand suggests that migraine significantly adds to the ischemic stroke risk posed by OC use, which may only be a risk factor at high doses of older preparations [18], and smoking.

In summary, the best evidence of the independent effect of migraine on ischemic stroke amongst women aged 45 years or more comes from the WHS [11], which found that migraine with aura was associated with almost a doubling of ischemic stroke risk, whereas migraine without aura increased risk by just less than 30%. This clear effect of aura is supported both by the ARIC study [24] and, to a limited extent, the case–control study meta-analysis [22]. All three of these analyses found a similar RR for migraine with aura, but the RRs for migraine without aura ranged from 0.86 to 1.83. The best estimate of the increased risk for ischemic stroke caused by migraine in women aged below 45 years is 130%, from the study of Nightingale et al. [23]. It would be expected that most migraineurs in this study would not be having attacks with aura [101], and thus the effect of aura in women younger than 45 years is likely to be even greater. Two of the three prospective studies of ischemic stroke amongst women and men combined [12,16] found a significant (p < 0.05) detrimental effect of migraine, whilst the third reported a doubling of the risk with aura, which was marginally insignificant [24]. Data not shown here suggest that there is no association between migraine and hemorrhagic stroke [16,25].

Conclusion

Although there are inconsistencies in the literature, this review suggests that, amongst women migraine with aura is independently associated with the risk of both CHD and ischemic stroke. This is in agreement with a recent critical appraisal [27]. Migraine without aura appears to have a more modest association. There appears also to be a stronger relationship between classical CVD risk factors and migraine with aura than without. The excess risk from migraine seems to diminish with a woman's age. As well as having a higher prevalence of migraine than men, women may also have proportionately slightly higher cardiovascular risks associated with migraine than men.

Although women with aura do seem to have more risk of CHD and ischemic stroke than nonmigraineurs, because of the relatively young age at which migraine prevalence peaks, and the relatively old age at which CHD and stroke death rates and incidence peak, the risk from migraine with aura is not large in absolute terms. For example, amongst women in the 35–44 years age group, which includes the age of peak prevalence of migraine [4], the death rate from CHD in the USA in 2004 was 17.7 per 100,000 [102], whilst ARIC data over the period 1987–2004 showed an incidence of MI for Whites of 0.3 per 1,000 women-years [103]. Suppose a liberal estimate of 2.5 for the relative risks of coronary death and MI, comparing migraineurs with aura to those with no migraine, in this age group. Also suppose that the prevalence of migraine in this age group is 27% [4], 17.5% of all migraineurs have aura [101] and that the RR comparing migraine with aura to migraine without aura is 1.7 [11]. The expected number of deaths and first MI events per year amongst female migraineurs with aura at the age of peak prevalence of migraine would then be approximately 38 per 100,000 and six per 10,000, respectively: less than one coronary death amongst every 2500, and less than one MI event amongst every 1500 migraineurs with aura. For ischemic stroke, in the same age group, the absolute risks would be lower.

These conclusions of this review are tempered by the shortage of studies on migraine and CVD. Whilst scores of studies and huge meta-analyses of prospective data have been published for leading CVD risk factors, such as blood pressure and serum total cholesterol, only seven independent prospective studies were identified in this review, one of which did not include women. The ability to compare studies and pool quantitative results meaningfully is hampered by the different ways in which migraine is defined and differences in the comparator groups, as well as the apparent variations in effect by age. Only two prospective studies [1,11,15,24] separated migraine with and without aura, and these studies suggest that this separation is vital to understanding the true etiology and formulating preventive strategies for CVD subsequent to identifying migraine. Even if there is a real association between migraine and CVD, it is not necessarily direct or even causal [28]; migraine and CVD have both, for instance, been linked with psychiatric disorders [2,29–31].

Nevertheless, any young or middle-aged woman who regularly experiences migraine with aura would be well advised to take action to improve her cardiovascular risk profile, which may include stopping smoking, taking more exercise and eating less saturated fat and salt. Owing to the low absolute risk of CVD in young age groups there is no contraindication to her use of OCs, in general [5]. Most importantly, she should consult with her doctor – in the USA, it has been reported that a third of female migraineurs have never consulted a doctor about their headaches [32]. Furthermore, 60% of female migraineurs do not use acute migraine medication and, even amongst those women who have had a positive diagnosis of migraine, more than a third are not taking any relevant prescription medication [33]. Triptans (drugs that act as selective serotonin agonists) are one type of treatment for those with migraine [34]. There is now plenty of evidence that triptans are both effective against migraine attacks [2,34,35] and pose no cardiovascular risk [12,16], although potential dangers of overuse have been cited [2].

Future perspective

A key issue in the epidemiology of migraine, which this review suggests to be important in relation to potential subsequent cardiovascular risk, is whether migraine with and without aura are really different diseases. If future research was able to settle this issue, some of the current confusion in causes and effects of migraine might be removed. In the conclusions given here, too much emphasis has had to be placed on the WHS, owing to limitations with the other studies. Although current guidelines on ischemic stroke prevention list migraine as a potential risk factor [18], this is not generally thought of as a risk factor for MI or CHD, and migraine is not included in the AHA guidelines for CVD prevention in women [36]. This is despite the results of the WHS, where the relative risk for MI (for migraine with aura) is substantial, and slightly higher than for stroke. Future AHA guidelines for CVD amongst women might, thus, consider migraine. On the other hand, the bulk of the evidence from other studies, besides the WHS, suggests that the relative risks are much lower for MI/CHD than for stroke ( Table 1 ). Also, there are far more studies of ischemic stroke than MI or CHD, even if most are of the case–control type. In the short term, it would be sensible to plan a careful case–control study of MI and migraine, to seek confirmation of the findings of the WHS. A cohort study would also be worthwhile, in order to provide more reliable results but at a relatively high cost and with a long delay [8]. Given the standard definition of migraine now established [101], any future prospective study should utilize this in order to study the effects of migraine accurately and produce generalizable results. This was not always possible in the past. There are few data on the effects of frequency and duration of migraine and types of aura, and it would be welcome to see such issues explored in future studies.

Executive summary

In the USA, migraine is common amongst women, of whom almost a fifth will have had an episode within the past year.

Migraine with aura is widely accepted as an independent risk factor for ischemic stroke amongst women up to the age of 60 years – smoking and oral contraceptive use might exacerbate the problem.

Migraine is also likely to be an independent risk factor for myocardial infarction, although data are scarse.

The most reliable data currently available suggests that migraine with aura will approximately double the risk of both stroke and myocardial infarction in women.

Women with migraine with aura should be considered for aggressive cardiovascular risk management, as well as antimigraine medication.

Footnotes

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

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Migraine and the Risk of Coronary Heart Disease and Ischemic Stroke in Women

Abstract

Keywords

Epidemiology of migraine

Cardiovascular risk factors in migraineurs & nonmigraineurs

Migraine & coronary heart disease

Migraine & ischemic stroke

Conclusion

Future perspective

Footnotes

References