Migrainous infarction

Shuu-Jiun Wang MD (Dr. Wang of the National Yang-Ming University School of Medicine and the Neurological Institute, Taipei Veterans General Hospital received consulting fees from Eli Lilly.)
Originally released July 1, 1993; last updated October 8, 2016; expires October 8, 2019

This article includes discussion of migrainous infarction, complicated migraine, migraine-induced stroke, migraine with cerebral infarction, migrainous stroke, and migraine-related stroke. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

In this article, the author updates the topic of migrainous infarction, including the diagnostic criteria proposed by the International Classification of Headache Disorders, 3rd edition (beta version), 2013. A patient with recurrent migrainous infarction was reported—1 in the cerebellum, the other in occipital lobe.

Key points

 

• Migrainous infarction is a rare complication after usual attacks of migraine with aura with a documentation of neuroimaging findings, such as MRI. Cortical laminar necrosis is one of the MRI findings.

 

• The incidence of migrainous infarction is very rare, estimated as 3.36 per 100,000 person-years according to the strict criteria proposed by the International Headache Society.

 

• Migrainous infarction mostly occurs in the posterior circulation and in younger women with a history of migraine with aura.

 

• The majority of patients present with visual prolonged aura, and the stroke severity is mild with a good outcome.

 

• The pathologic mechanisms responsible for migrainous infarction remain unproven. One case report suggests a continuum between migraine aura and stroke by cortical spreading depolarization.

Historical note and terminology

Migraine attacks are occasionally accompanied by stroke. Permanent neurologic deficits associated with attacks of migraine were reported as early as the 19th century. Charcot first used the term "complicated migraine" (Charcot 1890), and Galezowski reported persistent visual sequelae (Galezowski 1881). Hunt wrote a classic paper concerned with permanent paralysis along with other neurologic complications of migraine (Hunt 1915).

The diagnosis of migrainous infarction is based on the abrupt onset of a neurologic deficit during a migraine attack associated with evidence of cerebral infarction on neuroimaging. Other causes of stroke must be excluded. Strict criteria for the diagnosis of migrainous infarction must be applied because migraine is common and patients with migraine may suffer from other causes of stroke. The diagnosis of migrainous infarction should be made only when a patient with an established history of migraine suffers a cerebral infarction during a typical migraine attack (Rothrock et al 1988).

Welch proposed the following expanded International Headache Society classification to encompass all migraine-related strokes:

 

(1) Coexisting stroke and migraine
(2) Stroke with clinical features of migraine

 

(a) Symptomatic migraine
(b) Migraine mimic

(3) Migraine-induced stroke

 

(a) Without risk factors
(b) With risk factors

(4) Uncertain (Welch 1994).

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