Migraine and cardiovascular disease: What's the link?

What do cardiovascular disease and migraines have in common? For one, both conditions involve changes in blood vessels, blood flow, and inflammation. Another link: migraine sufferers younger than 45 who experience odd visual or physical sensations prior to the headache (see "What is a migraine aura?") may face an increased risk of stroke. Finally, the most common and effective class of drugs to treat migraine, triptans, have been linked to a higher risk of stroke and heart attack in people at risk for those cardiovascular conditions.

But if you're among the one in six people who copes with these debilitating, painful headaches, there's reassuring news: both of those risks are extremely small. Read on for more perspective, plus advice for migraine sufferers.

Anatomy of a migraine

"During a migraine, blood vessels lining the brain dilate in response to abnormal activity in cells in the cerebral cortex, the largest area of the brain. This triggers a cascade of inflammation and other processes that can spread throughout the brain," says Dr. Natalia Rost, professor of neurology at Harvard Medical School and chief of the Stroke Division at Massachusetts General Hospital. It's why migraines can cause a wide range of symptoms, including nausea, fatigue, or sensitivity to light. People tend to experience their own particular combination of symptoms that progress gradually during the migraine, often in a predictable pattern.

In contrast, the symptoms of a stroke appear suddenly. "If you feel numb or weak on one side of your face or body, are unable to speak normally, or lose vision, that's a 911 situation," says Dr. Rost. In people who get migraines, those same symptoms might be related to an aura. But play it safe and seek medical attention right away, she advises.

Most common in women

Migraines are about three times as common in women than men, for reasons that aren't entirely clear. Up to 30% of women ages 20 to 40 get migraines, but strokes are very rare among young women. Even if their risk of stroke doubled (as one study of people who have migraine with aura found), the overall prevalence is still very low. Still, women who have migraine with aura should be sure to tell their primary care provider or gynecologist about their headaches. Taking estrogen-containing birth control pills or hormone therapy may further raise stroke risk in these women. As a result, they might want to consider nonhormonal or estrogen-free treatment options.

Treating migraines

Last year, a study based on real-world data from patients ranked the class of drug known as triptans as the most helpful treatment option for quelling their migraine symptoms. But these drugs — which include eletriptan (Relpax) and zolmitriptan (Zomig) — aren't recommended for people with cardiovascular disease, based on evidence that these drugs may raise the risk of stroke and heart attack. Earlier this year, findings from a study of more than 400,000 people who received a triptan prescription confirmed that observation. However, the absolute risk of a cardiovascular problem was very low — around one in 30,000. Most of the stroke and heart attacks occurred in people with risk factors for heart disease, such as high blood pressure, high cholesterol, and diabetes.

"What struck me was how rare these events were among this huge population," says Dr. Rost. Still, she recommends a personalized approach when selecting medications for migraine sufferers who have or are at risk for cardiovascular problems. Newer migraine drugs known as calcitonin gene-related peptide (CGRP) inhibitors don't appear to have any significant side effects related to blood vessels, but the long-term effects are still unknown. CGRP inhibitors approved for acute migraine treatment include oral rimegepant (Nurtec) and ubrogepant (Ubrelvy) and nasal zavegepant (Zavzpret).

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