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  • Updated 04.08.2024
  • Released 07.01.1993
  • Expires For CME 04.08.2027

Migrainous infarction



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, 2018.

Key points

• Migrainous infarction is a rare complication after usual attacks of migraine with aura with 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 at 3.36 per 100,000 person-years according to the strict criteria proposed by the International Headache Society. It is mandatory to exclude cerebral infarctions in cases where patients experience an atypical aura even in the context of established migraine.

• 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 good short-term and long-term outcomes.

• Several mechanisms are proposed to link migraine and stroke, with genetic predisposition, aura-related electrophysiological mechanisms (cortical spreading depolarization), and cerebral microembolism being the most convincing ones.

• The pathologic mechanisms responsible for migrainous infarction remain unproven, and a continuum between migraine aura and stroke by cortical spreading depolarization is suggested.

• Post-stroke headache, which is different from migrainous infarction, is not considered rare and ranges from 1% to 23% after ischemic stroke.

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" (13), and Galezowski reported persistent visual sequelae (21). Hunt wrote a classic paper concerned with permanent paralysis along with other neurologic complications of migraine (27).

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. It is mandatory to exclude cerebral infarctions in cases where patients experience an atypical aura even in the context of established migraine (24). 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 (54).

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