Migraine with aura is associated with an approximately 2-fold increased risk of ischaemic stroke [2-4]. âHowever, the mechanism behind this relationship is largely unknown,â said Dr Nikita Chhabra (Mayo Clinic, NY, USA). Migraine with aura is associated with an increased risk of cardioembolic stroke when compared with migraine without aura, but not with risk of lacunar or non-lacunar thrombotic stroke [5]. Interestingly, higher incidence of AF has been demonstrated in patients with migraine with aura than in those without aura in longitudinal cohort studies [6].
These findings may imply that AF-associated cardioembolism plays a key role in the interaction between migraine and stroke. However, investigating this hypothesis has many challenges. Firstly, AF is difficult to detect given its paroxysmal nature. Furthermore, long-term cardiac monitoring is expensive, time-consuming, low-yield, and often not justified in patients with few vascular risk factors [7]. Prior to developing clinical AF, structural changes occur in the atria that predispose patients to future risk of atrial arrhythmias [8]. These changes might be reflected on ECGs, but could be too subtle to be detected by human eyes.
The cardiology team at Mayo Clinic developed a new way of predicting subclinical AF: an AI-enabled ECG algorithm that can predict the probability of paroxysmal AF based on a single sinus rhythm ECG [9]. In ECGs that were interpreted as normal sinus rhythm by cardiologists, this algorithm was able to identify and predict the probability of paroxysmal AF with a sensitivity of 79.0% and a specificity of 79.4%. This is relevant because few patients with migraine have undergone long-term cardiac monitoring, but many have had routine ECGs at some point during their treatment course for migraine or other medical conditions. The AI-enabled ECG algorithm could be a powerful tool that is readily available to help elucidate the association between migraine, AF, and stroke.
After excluding patients with a previous confirmed AF diagnosis, 676 migraine patients with aura and 1,124 patients without aura were analysed in the current study [1]. The migraine with aura group was significantly older than the migraine without aura group (50.2 vs 46.6 years; P<0.001). After adjustment for age and sex, patients with aura were found to have a higher mean probability of AF than those without aura (7.6% vs 5.9%; P=0.003). Interestingly, the difference of AF probability between migraine patients with and without aura was significant in men (P=0.043), but not in women (P=0.079). Since autonomic dysfunction has a role in the pathophysiology of both migraine and AF, it begs the possibility that migraine with aura development is attributable to cardioembolic stroke arising from AF.
These results are consistent with results observed from longitudinal cohorts and support the theory that AF-mediated cardioembolism plays a key role in the association between migraine and stroke, especially in patients with migraine with aura.
- Chhabra N, et al. An AI-enabled ECG Algorithm Predicts Higher Subclinical Atrial Fibrillation Risk in Patients with Migraine with Aura Compared to Migraine without Aura. AL02, IHC 2021, 8â12 September.
- Ăie LR, et al. J Neurol Neurosurg Psychiatry. 2020;91(6):593â604.
- Spector JT, et al. Am J Med. 2010;123(7):612â24.
- Etminan M, et al. BMJ. 2005;330(7482):63.
- Androulakis XM, et al. Neurology. 2016;87(24):2527â32.
- Sen S, et al. Neurology. 2018;91(24):e2202â10.
- Seet RCS, et al. Circulation. 2011;124(4):477â86.
- Kottkamp H. Eur Heart J. 2013;34(35):2731â8.
- Attia ZI, et al. Lancet. 2019;394(10201):861â7.
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Table of Contents: IHC 2021
Featured articles
Letter from the Editor
COVID-19
Telemedicine beneficial for headache care during the pandemic
Comparison of headaches after SARS-CoV-2 vaccination
Grey matter cortical changes in patients with persistent headache after COVID-19
Increased risk of cerebral venous thrombosis in COVID-19
Patient Perception and Symptoms
Predictors of health-related quality of life in cluster headache
Dry eye disease is more prevalent in migraine
Voice change and throat swelling are cranial autonomic symptoms in primary headache
Association between physical inactivity and headache disorders
Increased suicidal attempts and risks of ideation in medication-overuse headache
Cardioembolic Comorbidities
AI-enabled ECG algorithm predicts atrial fibrillation risk in migraine
Migraine may not be a risk factor for stroke
Imaging
Functional brainstem somatotopy of the trigeminal nerve during nociception
Morphological changes in cluster headache between attacks
Interictal pontine metabolism in migraine patients without aura
Genome-Wide Association Studies
Largest genome-wide association study of migraine to date
Robust evidence that cluster headache has a genetic basis
Pharmacological Treatment
Insights in drug-drug interactions facilitate rational polypharmacy
Rimegepant confers long-term improvements in MMDs
First real-world effectiveness data of erenumab is promising
Galcanezumab effective in patients with episodic or chronic cluster headache
Central effects and affected somatosensory processing with galcanezumab in migraine
Long-term safety and tolerability of atogepant in migraine
Non-Pharmacological Treatment
Occipital nerve stimulation effective and safe in chronic cluster headache
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