Migraine, a neurological disorder characterised by severe and recurrent headaches, has long been a subject of medical interest due to its debilitating nature.

Recent research has unveiled a complex association between migraine and heart disease, broadening our understanding of these two conditions.

Migraine and stroke

Studies have shown that patients with migraines could experience “ischemic” strokes more often and at an earlier age than those without migraines, with an average difference of five to seven years. Ischemic strokes are the most common type of cerebrovascular accidents, and are characterised by a cut in blood supply to a part of the brain.

In addition, haemorrhagic strokes, characterised by bleeding in the brain, have also been reported to be more prevalent among migraine sufferers. Furthermore, women who have experienced migraines and used oral hormonal contraceptives were found to have a seven-fold higher risk of stroke.

Migraine is often coupled with an “aura”. Migraine aura refers to an array of vision disturbances including dots, sparks or zigzags. Some people may also experience ear ringing, dizziness or even the inability to speak clearly. An aura may occur prior to or during a migraine attack. At times, an aura can develop without concomitant or subsequent headache. In this instance, it could be confused with a stroke or a mini-stroke, called “TIA”.

Migraine and heart disease

Migraine is associated with various forms of heart disease:

1, People with migraines exhibit a higher prevalence – of about 30 per cent – of chest pain or “angina pectoris”, and heart attack or “myocardial infarction”, compared to those without migraines.

This association is particularly pronounced in individuals with migraine and aura, while migraine without aura appears to be linked to a lower risk of angina. Genetic studies have identified DNA linkage between migraine and coronary plaques formation, more than what is randomly expected. The nature of this linking is being actively investigated.

2, In addition, migraine has also been associated with “vasospastic angina”, a condition characterised by sudden spasm of coronary arteries even if they are otherwise plaque-free. The underlying mechanism of this connection remains again unclear, but both conditions seem to be related to a dysfunction of the lining of vessels, called “endothelial dysfunction”, in both brain and heart arterial trees.

3, Another possible explanation for the link between migraine and heart disease is the presence of shared risk factors. Individuals with migraines often exhibit obesity and high blood pressure, which are known contributors to heart disease. This commonality suggests that addressing these risk factors may help mitigate the risk of both conditions.

4, A fascinating aspect of the migraine-heart disease connection is “neurogenic inflammation”. Migraines are believed to be triggered by the release of small molecules in the brain circulation called “neuropeptides” that cause inflammation and pain in the head. These neuropeptides, such as calcitonin gene-related peptide (CGRP), are also implicated in the development of atherosclerosis or coronary plaques.

5, Patent Foramen Ovale, or PFO, is a congenital anatomical heart variant characterised by an open flap-like hole between the heart's upper chambers or atria. PFO is frequently detected in people with migraine, occurring in approximately 50 per cent of cases compared to 20 per cent in those without migraine. While trials have not consistently demonstrated the superiority of PFO closure over medical therapy in reducing migraine attacks, large analyses suggest that PFO closure could abolish migraines in some subsets of patients and reduce monthly migraine days.

6, Stress is a known trigger for both migraines and heart disease. Chronic stress can lead to the release of stress hormones, which may exacerbate above described mechanisms of vascular dysfunction and inflammation. Moreover, the psychological toll of living with chronic migraines may contribute to stress-related heart disease. Managing stress through lifestyle modifications, stress-reduction techniques and medications may be beneficial for individuals with both conditions.

7, Another intriguing aspect of the relationship between migraine and heart disease is the potential influence of drugs used to treat migraine headaches. Some commonly prescribed medications, such as triptans, have a constricting effect on the heart vessels and could impact cardiovascular wellbeing, especially in individuals with pre-existing cardiac disease. Examples of triptans include sumatriptan (Imitrex), Frovatriptan (Frova) and naratriptan (Amerge).

In addition, chronic use/overuse of non-steroidal anti-inflammatory drugs to treat migraine raises concerns due to a higher risk of NSAIDS-induced hypertension, another significant cardiac risk. Examples of NSAIDs include Naproxen, Ibuprofen, and Celebrex.

In conclusion, the connection between migraine, stroke and cardiac disease is intricate and multifaceted. The management of migraine in individuals with heart conditions requires a nuanced approach, taking into account the overlapping risk factors discussed above, along with the potential cardiovascular side effects associated with headache treatments.

• Joe Yammine, MD is a consultant cardiologist at the Bermuda Hospitals Board. The information here is not intended as medical advice or as a substitute for professional medical opinion. Always seek the advice of your physician