Disclosure Objectives - American Headache Society

Conditions and Cases of Vascular Disease
and Headache
David W. Dodick M.D.
Professor
Department of Neurology
Mayo Clinic
Phoenix Arizona
Disclosure
• Consulting: Allergan, Amgen, Arteaus, Alder, ATI, BMS, Merck,
Labrys, Zogenix, e-Neura, NuPathe.
©2013 MFMER | slide-2
Objectives
• Describe the relationship between
between migraine and stroke, and discuss
the clinical implications
• Discuss the diagnostic and treatment
approach to selected cases of migraine
and vascular disease
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Migraine & Ischemic Stroke
Meta-analyses
Etmiman M., et al. BMJ 2005; 330: 63
Schurks M., et al. BMJ 2009; 339: b3914
Spector JT., et al. Am J Med 2010; 123: 612–24
Relative Contribution of Migraine With
Aura on Stroke Subtypes in Women
• Prospective cohort study of 27,860 women aged ≥45
participating in the Women's Health Study
• Migraine (5130; 18.4%) with aura (40%)
• 15 year follow-up (528 total strokes; 430 ischemic)
Kurth T. et al. Cephalalgia 2013;33:Suppl8:18-19
Adjusted Absolute Event Rate per 1000 Women
Per Year Migraine With Aura
Kurth T. et al. Cephalalgia 2013;33:Suppl8:18-19
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No association with non-vascular
medical diseases (e.g. pneumonia,
post-partum hemorrhage, infections)
Study may underestimate association
because of lack of migraine diagnosis
coding
Bushness CD, et al. BMJ 2009;338:b664
Migraine and Hemorrhagic Stroke
A Meta-analysis
Sacco S, et al. Stroke. 2013;44:3032-3038
Mechanism of Stroke in Individuals With
Migraine with Aura
• CSD induced infarction (migrainous infarction – very rare)
• Disorders of vessel wall, blood, heart that increase risk of
‘symptomatic’ migraine and stroke
• MA comorbid with diseases/conditions that increase stroke risk
• Endothelial dysfunction
• Genetic vulnerability to both CSD and ischemia
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• earlier anoxic depolarization
• rapid expansion of infarct core
• higher CBF threshold required for tissue
survival
Mild ischemia may predispose to strokes in
migraineurs that would otherwise be
asymptomatic or result in TIA
Eikermann K, et al. Circulation 2012;125:335-345
Migraine is Associated with
Rapid Infarct Growth
DWI/PWI >0.9
(No penumbra)
No
migraine
Any
migraine
Migraine
+ aura
4%
36%*
56%†
“Shorter time window for acute intervention in stroke
patients with history of migraine”
*p=0.011 Any migraine vs. No Migraine
†p=0.002 Migraine w/ aura vs. No migraine
Cephalalgia 2013;33:75.
N=139 infarct size 3.24 times larger
(p<0.004) in those with aura
Eikermann-Haerter et al. Cephalalgia 2013;33:229.
Cephalalgia 2013;33:.252-253
Lamotrigene and Topiramate
reduce infarct size and improve
neurological outcome
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CLINICAL IMPLICATIONS
• Migraine increases risk of ischemic and hemorrhagic
stroke in women of all ages (absolute risk ~4000/year)
• Assess for migraine in stroke patients and code correctly
• Counsel women with migraine on vascular risk during
pregnancy
• Address traditional RF’s in migraine + aura (no smoking!)
• Effect of migraine prevention (class of drug) on stroke
risk unknown
WHAT ABOUT ASPIRIN?
Aspirin (<300mg) was associated with a 55% relative
risk increase in major bleeding; this translates to 2
excess cases for 1000 patients treated per year (same
magnitude as primary risk reduction for major CV
adverse events when 10-year risk is 10-20%)
De Berardis G. et al. JAMA. 2012;307(21):2286-2294
WHAT ABOUT COMBINED ORAL
CONTRACEPTIVE PILLS?
• IHS: Low-dose estrogen in
women with ‘simple’ visual aura
• ACOG: recommends against
COC in migraine + aura (<35)
and in MA and MO (>35)
• WHO: Absolute
contraindication in all women
with aura
• No contraindication in MO
• In MA, do not use
• Recent onset aura
• Sensory, language
and motor aura
• Frequent aura
• Presence of other risk
factors (smoking,
hypertension, coagulopathy)
ACOG, American College of Obstetricians and Gynecologists;
IHS, International Headache Society; WHO, World Health Organization
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CASE
• 51 YO woman with migraine
without aura, and known (2006)
4mm P-Comm artery aneurysm
• Presents 6 hrs after onset of TCH
• Examination, CT head & CSF
normal; OP 14 cm H20
• MRI brain normal; MRA brain
unchanged 4mm P-Comm artery
aneurysm
What to do?
A. Reassure; continue to follow with serial MRA
B. Refer for surgical clipping of aneurysm
C. Refer for endovascular coiling of aneurysm
ARS Question
Questions
• What is the evidence that an unruptured ICA can present with
TCH?
• What percentage of TCH patients have SAH?
• 7-13%
• What percentage of TCH patients have unruptured aneurysm?
• 3.6-6% (93% <7mm)
• What is the risk of doing nothing?
• What is the risk of doing something?
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Unruptured Intracranial Aneurysms
Five-Year Rupture Rates
Location
Cavernous
carotid
<7mm
<7mm
7-12mm
13-24mm
>25mm
(Group 1)
0
(Group 2)
0
0
3
6.4
AC/MC/IC
0
1.5
2.6
14.5
40
Post-Circ
2.5
3.4
14.5
18.4
50
1692/4060 UIA followed prospectively for 5 years
Group 1: No history of SAH
Group 2: History of SAH
Weibers DO, et al. Lancet 2003, 362:103–110.
Morbidity and Mortality of Clipping and
Coiling UIAs (2001-2008)
Brinkikji W. et al. AJNR 2011;32:1071–75
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What to do?
A. Reassure; continue to follow with serial MRA
B. Refer for surgical clipping of aneurysm
C. Refer for endovascular coiling of aneurysm
ARS Question
Case
• 33 year-old woman with history of celiac disease, migraine without
aura. Was taking Delsym with Vicks for URI 2 weeks ago.
• Thunderclap headache bilateral occipital/vertex
• Vertigo, nausea, emesis, right arm/leg weak/incoordination
• Exam: Diplopia right lateral gaze, 3+/5 R>L upper; 4/5 R>L lower;
right arm ataxia; gait ataxia, bilateral suboccipital tenderness
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What Test Would You Order Now?
A. Transthoracic echocardiogram
B. Transesophageal echocardiogram
C. Lumbar Puncture
D. MRI brain
ARS Question
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Migraine and Cervical Artery Dissection:
Meta-analysis of 5 Case-control Studies
Rist PM, et al .Cephalalgia 2011; 31: 886–96
Which of the following is your next
step?
1. Start ASA 81mg
2. Start Clopidogrel 75mg
3. Start ASA 81mg and warfarin
4. Start heparin and warfarin
5. Neither antiplatelet nor anticoagulant
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Vertebral versus Carotid Artery Dissection
• Compared with sICAD, sVAD 1
• Most common in young women
• >6X more often assoc with ischemic stroke; 11X with SAH
• >2x more often associated with thunderclap headache
• 25% associated with RCVS
• Mechanism of stroke thromboembolic in 88% 2
• VAD – 46% recanalize at 3 months3
1. Von Babo et al. Stroke 2013;44:1537-1542
2. Morel A., et al. Stroke. 2012;43:1354-1361
3. Arauz A, et al. Stroke. 2010;41:717-721.)
• 2 meta-analysis show no difference between ASA and warfarin
• In CAD, incident ischemic stroke rare (0.3%), (TIA/Amurosis
4.4%) and no difference between ASA and Warfarin
• Adverse hemorrhagic events (2% warfarin; 1% aspirin)
• Recurrent stroke significantly more frequent in those with
ischemic event at onset (6.2% vs 1.1%)
Giorgiadis et al. Neurology 2009;72:1810–1815
THANK YOU!
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