HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

Correspondence to:

ARTICLES: Didier Milhaud, Julien Bogousslavsky, Guy van Melle, and Pierre Liot Ischemic stroke and active migraine Neurology 2001; 57: 1805-1811 [Abstract] [Full text] [PDF]

Correspondence: Submit a response to this article

Correspondence published:

Reply to both Letters to the Editor

Didier Mihaud, Julien Bogousslavsky   (19 February 2002)

Ischemic stroke and active migraine

Josef G Heckmann, C J G Lang and B Neundorfer   (19 February 2002)

Ischemic stroke and active migraine

Gregorio Zlotnik   (19 February 2002)

Reply to both Letters to the Editor 19 February 2002
Didier Mihaud University Hospital Lausanne, Julien Bogousslavsky Send Correspondence to journal: Re: Reply to both Letters to the Editor dmilhaud{at}yahoo.fr Didier Mihaud, et al.	We were very interested by the comment of Dr Zlotnik about our article. [1] Dr Zlotnik remarks that migrainous patients with stroke sometimes use aspirin-containing drugs or triptans, and that this may influence the outcome of cases in which thrombotic events are considered. However, in our study, 14 patients out of 130 (11 %) were using a migraine prophylaxis drug (dihydroergotamine in nine and flunarizine in five), while, to treat a migraine attack, only eight patients (6 %) with migraine and stroke regularly used aspirin-containing drugs, while about two-thirds used paracetamol-containing drugs. This rate of treatment is similar to that in another community-based study of medication patterns for 274 frequent headache sufferers who reported 12 or more headaches a year, in which 60 % of patients used paracetamol for migraine attack, while only 12 % used prescription medication. [3] In our study, no patients used triptans. We conclude that the low rate of aspirin intake cannot influence the outcome of ischemic stroke occurring in our migrainous patients when compared with control patients. We appreciate the comment of Heckmann et al. who reported a new case of an 80-year-old patient who suffered "ischemic stroke occurring during an attack of migraine" without any other determined cause (ISODAM). To reply to their question, the age range in our group of older migrainous patients with ischemic stroke was 45-79 years and the oldest patient with ISODAM was 67-years-old. These authors speculate that, in migraineurs with aura, an impaired cerebrovascular autoregulation may play a physiopathological role in ISODAM, which can also occur in old patients {2}. We agree with their analysis, but, in our study, the prevalence of migraineurs in our ischemic stroke population aged 45 and older was lower (2.1 %) that in the general population, suggesting that brain infarcts after 45 years may be less frequent in migraineurs than in nonmigraineurs. Moreover, there is a hint in our data that migraineurs (young or old) may more frequently have a more favorable outcome at 1 month than nonmigraineurs. We agree that old migraineurs might develop ISODAM by impairment of cerebrovascular autoregulation, but speculate that this impairment could also be responsible for other phenomena, such as the development of secondary collateral pathways limiting the occurrence and size of brain infarcts. Reference 1-Milhaud D, Bogousslavsky J, van Melle G, Liot P. Ischemic stroke and active migraine. Neurology 2001; 57:1805-1811. 2- Heckmann JG, Hilz MJ, Katalinic A, Marthol H, Mück-Weymann M, Neundörfer B. Study on myogenic cerebrovascular autoregulation in migraine without and with aura using stress-TCD. Cephalalgia, 1998;18:133-137. 3- Forward SP, McGrath PJ, Mackinnon D, Brown TL, Swann J, Currie EL. Medication patterns of recurrent headache sufferers: a community study. Cephalalgia 1998;18(3): 146-151.
Ischemic stroke and active migraine 19 February 2002
Josef G Heckmann University of Erlangen-Nuremberg Erlangen Germany, C J G Lang and B Neundorfer Send Correspondence to journal: Re: Ischemic stroke and active migraine Josef.Heckmann{at}neuro.imed.uni-erlangen.de Josef G Heckmann, et al.	We appreciate the study on ischemic stroke and active migraine by Milhaud et al. [1]. They concluded that migraine is frequent in young stroke patients and infrequent in older patients and is related to age. In the result section (table 2) they report on the age of the migraineurs whose mean and standard deviation was 57.6+9 years. Unfortunately they did not mention the range of age in this subgroup. Recently we discussed whether there is an age limit for migrainous stroke prompted by the following case history. An 81-year-old woman had a 45-year history of migraine attacks with and without aura including mostly unilateral throbbing headache associated with nausea, vomiting, phono- and photophobia. The headache attacks occurred about two to three times a month unchanged by menopause. An acute severe attack associated with visual aura symptoms and disturbances in her right visual fields led to the admission. Neurologic examination revealed a right-sided hemianopia. MRI scan demonstrated an infarction in the territory of the left posterior cerebral artery. After treatment (acetylsalicylate, metoclopramide) the headache and nausea resolved within 12 hours, the hemianopia, however, persisted. Further investigations with respect to cardioembolic, hemodynamic or local thrombotic stroke did not show abnormal results. The topic of migraine-associated stroke is still a matter for debate. Typically, an ischemia-induced migraine attack may be more frequent than migraine-induced ischemic insults. [2] Because of the close time relationship in our patient beween the visual aura, the headache and the neurologic sequelae, we believe that the patient suffered ischemic stroke occuring during an attack of migraine (ISODAM). Modern pathophysiological theories attribute migraine pain to vascular dilation and perivascular nociceptor activation while identifying spreading cortical depression as the mechanism underlying the migraine aura with involvement of the trigeminovascular system. [3, 4] Epidemiological data, as in Milhaud et al. study [1], suggest that these phenomenon may be age-dependent. However, the question remains, why in some patients the risk of ISODAM is still present in old age. We speculate that in migraineurs with aura an impaired cerebrovascular autoregulation may play a pathophysiological role along side other factors which are not yet known. [5] We wish to add one patient´s history to the small subgroup of ISODAM-patients older than 45years – three out of 3,873 first ever ischemic stroke patients in [1] - emphasizing that ISODAM can also occur in patients over the age of 80. References 1. Milhaud D, Bogousslavsky J, van Melle G, Liot P. Ischemic stroke and active migraine. Neurology 2001;57:1805-1811. 2. Heckmann JG, Lang CJG, Dietrich W, Neidhardt B, Neundörfer B. Symptomatic migraine linked to stroke due to paradoxical embolism and elevated thrombosis risk. Cephalalgia 2002, in press. 3. Goadsby PJ, Olesen J. Diagnosis and management of migraine. BMJ 1996;312:1279-1283. 4. Weiller C, May A, Limmroth V, Jüptner M, Kaube H, van Schayk R, Coenen HH, Diener HC. Brainstem activation in spontaneous human migraine attacks. Nature Med 1995;1:658-660. 5. Heckmann JG, Hilz MJ, Katalinic A, Marthol H, Mück-Weymann M, Neundörfer B. Study on myogenic cerebrovascular autoregulation in migraine without and with aura using stress-TCD. Cephalalgia, 1998;18:133-137.
Ischemic stroke and active migraine 19 February 2002
Gregorio Zlotnik Montreal Migraine Clinic Montreal Quebec Canada Send Correspondence to journal: Re: Ischemic stroke and active migraine cephalee{at}total.net Gregorio Zlotnik	An important factor was not mentioned in the recent study by Milhaud et al. [1] We know that migraine is frequently associated with other types of headaches, mostly tension-type headaches. These patients and migraine patients in general use over the counter medications. This includes aspirin (ASA)-containing drugs and ASA may influence the outcome of cases in which thrombotic events are considered. The usage of ASA was not mentioned in the different groups analyzed. Furthermore, the use of triptans also may have an influence in the outcome. Triptans are frequently being used in migraine treatment. Although potentially confusing, it would be interesting to review the same cases under another set of variables. It is sometimes preferable to be puzzled rather than mistaken. Reference: 1. Milhaud D, Bogousslavsky J, van Melle G, Liot P. Ischemic stroke and active migraine. Neurology 2001:57:1805-1811.