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IMPORTANCE Although sparse observational studies have suggested a link between migraine Supplemental content
and cervical artery dissection (CEAD), any association between the 2 disorders is still
unconfirmed. This lack of a definitive conclusion might have implications in understanding
the pathogenesis of both conditions and the complex relationship between migraine and
ischemic stroke (IS).
OBJECTIVE To investigate whether a history of migraine and its subtypes is associated with
the occurrence of CEAD.
MAIN OUTCOMES AND MEASURES Frequency of migraine and its subtypes in patients with
CEAD IS vs non-CEAD IS.
RESULTS Of the 2485 patients (mean [SD] age, 36.8 [7.1] years; women, 1163 [46.8%])
included in the registry, 334 (13.4%) had CEAD IS and 2151 (86.6%) had non-CEAD IS.
Migraine was more common in the CEAD IS group (103 [30.8%] vs 525 [24.4%], P = .01), and
the difference was mainly due to migraine without aura (80 [24.0%] vs 335 [15.6%],
P < .001). Compared with migraine with aura, migraine without aura was independently
associated with CEAD IS (OR, 1.74; 95% CI, 1.30-2.33). The strength of this association was
higher in men (OR, 1.99; 95% CI, 1.31-3.04) and in patients 39.0 years or younger (OR, 1.82;
95% CI, 1.22-2.71). The risk factor profile was similar in migrainous and non-migrainous Author Affiliations: Author
patients with CEAD IS (eg, hypertension, 20 [19.4%] vs 57 [24.7%], P = .29; diabetes, 1 [1.0%] affiliations are listed at the end of this
article.
vs 3 [1.3%], P > .99).
Group Information: The Italian
Project on Stroke in Young Adults
CONCLUSIONS AND RELEVANCE In patients with IS aged 18 to 45 years, migraine, especially (IPSYS) Investigators are listed in
migraine without aura, is consistently associated with CEAD. This finding suggests common eAppendix 1 in the Supplement.
features and warrants further analyses to elucidate the underlying biologic mechanisms. Corresponding Author: Alessandro
Pezzini, MD, Dipartimento di Scienze
Cliniche e Sperimentali, Clinica
Neurologica, Universit degli Studi di
Brescia, P.le Spedali Civili, 1, 25123
JAMA Neurol. doi:10.1001/jamaneurol.2016.5704 Brescia, Italia (alessandro.pezzini
Published online March 6, 2017. @unibs.it).
(Reprinted) E1
A
lthough spontaneous cervical artery dissection (CEAD)
is the most frequent cause of ischemic stroke (IS) in Key Points
young and middle-aged adults, the mechanisms lead-
Question Is there a link between migraine and cervical artery
ing to vessel damage are still unclear.1 A reason for this lack of dissection?
clarity is the limited number of large epidemiologic studies
Findings In this cohort study of 2485 patients aged 18 to 45 years
aimed at investigating this unusual disease that have been con-
with first-ever acute ischemic stroke, a history of migraine,
ducted thus far. In particular, what is poorly defined is the ef-
especially the subtype without aura, was independently
fect that specific susceptibility factors might have on disease associated with cervical artery dissection. The strength of this
risk. This is especially true for migraine. Scarce reports, mainly association was higher in men and in younger individuals.
derived from case series and case-control studies conducted
Meaning In young patients with ischemic stroke, migraine is
on small cohorts, have observed a higher prevalence of mi-
consistently associated with cervical artery dissection. This finding
graine in patients with spontaneous CEAD compared with pa- implicates possible common biologic mechanisms underlying the 2
tients with an IS due to a cause other than CEAD (non-CEAD disorders.
IS).2 To our knowledge, the international Cervical Artery Dis-
section and Ischemic Stroke Patients (CADISP) case-control
study3 is the only study confirming these findings in a large Risk Factor Definition
cohort and providing support for the idea that such an asso- The following risk factors for premature cerebral ischemia were
ciation may vary according to migraine subtype, being stron- documented: hypertension, diabetes, cigarette smoking, hy-
ger for migraine without aura. Apart from the contribution that percholesterolemia, and migraine. These variables were de-
these findings might have for better understanding the biol- fined and dichotomized as follows: hypertension, with sys-
ogy of arterial dissection, they also might have potential im- tolic blood pressure 140 mm Hg or higher and diastolic pressure
plications in elucidating the specific pathways underlying the 90 mm Hg or higher in 2 separate measurements after the acute
widely accepted association between migraine and IS in young phase or use of antihypertensive drugs before recruitment; dia-
adults. In this regard, any association between this primary betes, with a history of diabetes, use of a hypoglycemic agent
headache and spontaneous CEAD deserves to be further sub- or insulin, or fasting glucose level 126 mg/dL or higher (to con-
stantiated, and the characteristics of migrainous patients with vert to millimoles per liter, multiply by 0.0555); current smok-
IS caused by CEAD should be better defined. We aimed to evalu- ing, including former smokers who had quit smoking for 6
ate the association between migraine and spontaneous CEAD, months before the index event; and hypercholesterolemia, with
as well as the effect of specific migraine subtypes on disease cholesterol serum levels 220 mg/dL or higher (to convert to mil-
risk, in the Italian Project on Stroke at Young Age (IPSYS), one limoles per liter, multiply by 0.0259) or use of cholesterol-
of the largest registries of patients with early-onset IS that is lowering drugs.
currently available.
Assessment of Migraine History
The personal history of headache was assessed in all patients
by study physicians (all but M. Grassi, L.I., and A. Padovani)
Methods during a face-to-face interview in both the acute-phase and fol-
Study Design and Patients Selection low-up evaluations. A history of migraine before stroke oc-
The IPSYS is a countrywide network of neurologic centers with currence was considered for the present analysis. The diag-
a special interest in cerebral ischemia occurring at a young age noses of migraine without aura and migraine with aura were
across Italy, aimed at recruiting white patients with first-ever made according to the diagnostic criteria of the International
acute stroke who fulfill the following criteria: (1) age 18 to 45 years Headache Society.6,7
and (2) computed tomographic (CT) or magnetic resonance
imaging (MRI)proven cerebral infarction in the setting of a Clinical and Laboratory Investigations
hospital-based, multicenter, observational study. Centers are in- All patients underwent an etiologic workup, including com-
cluded in the network provided that the recruitment process of plete blood cell count; biochemical profile; urinalysis; 12-
stroke cases takes place prospectively. For the purpose of the lead electrocardiogram; chest radiography; Doppler ultraso-
present analysis, we screened data sets from patients consecu- nography, with frequency spectral analysis and B-mode
tively admitted to 26 hospitals. The recruitment period was Janu- echotomography of the cervical arteries; transcranial Dop-
ary 1, 2000, through June 30, 2015. Stroke was defined as a sud- pler ultrasonography; and CT and/or MR angiography, to in-
den loss of global or focal cerebral function that persisted for vestigate extracranial and intracranial vessels. Coagulation test-
more than 24 hours with a probable vascular cause. Ischemic ing included prothrombin and activated partial thromboplastin
stroke due to sinus venous thrombosis, vasospasm after sub- times, lupus anticoagulant, circulating antiphospholipid an-
arachnoid hemorrhage, and cardiac surgery; IS occurring as an tibodies (anticardiolipin antibodies and anti2-glycoprotein
immediate consequence of trauma; and iatrogenic strokes were I antibodies), fibrinogen, protein C, protein S, activated pro-
excluded.4,5 All aspects of the study were approved by relevant tein C resistance, antithrombin III, and genotyping to detect
local authorities at each study site (eAppendix 2 in the Supple- factor V Leiden and the G20210A mutation in the prothrom-
ment). Written informed consent was obtained from all patients bin gene. Transthoracic and/or transesophageal echocardiog-
or their guardians. raphy were performed to rule out cardiac sources of emboli.
In particular, the presence of patent foramen ovale (PFO) was with 95% CIs. P .05 determined with a 2-sided test was con-
assessed in all patients with transesophageal echocardiogra- sidered significant. Data were analyzed using SPSS, version 16.0
phy with a contrast study and Valsalva maneuver or transcra- (http://www.spss.com).
nial Doppler sonography with intravenous injection of agi-
tated saline (contrast-enhanced transcranial Doppler),
according to validated protocols.4,5
Results
Diagnosis of CEAD The present study targeted 2485 patients enrolled in the
Four-vessel conventional angiography, MRI with MR angiog- IPSYS registry. Among these, 334 patients (13.4%) had a diag-
raphy (3-dimensional time of flight), and/or CT angiography nosis of CEAD IS and 2151 individuals (86.6%) had a diagno-
of the brain and neck were included in the diagnostic workup. sis of non-CEAD IS. The mean (SD) age of the patients was
The presence of the double-lumen sign (a false lumen or an 36.8 (7.1) years, and 1163 participants (46.8%) were women.
intimal flap), luminal narrowing with the string sign, and As expected, patients with non-CEAD IS were more likely to
gradual tapering ending in total occlusion of the lumen (flame- have an unfavorable cardiovascular risk factor profile,
like occlusion) were considered reliable angiographic find- including diabetes, hypercholesterolemia, and current
ings of CEAD, whereas a narrowed lumen surrounded by a smoking status. Migraine was more common in the sub-
semilunar-shaped intramural hematoma on axial T1- group of patients with CEAD IS (103 [30.8%] vs 525 [24.4%],
weighted images was considered the pathognomonic MRI P = .01). This was mainly due to difference in the frequency
sign.8 of migraine without aura (80 [24.0%] vs 335 [15.6%],
P < .001), while the frequency of migraine with aura did not
Definition of Traumatic CEAD differ significantly in the 2 subgroups (21 [6.3%] vs 190
We considered the mechanisms of trauma associated with [8.8%], P = .12). The demographic characteristics of the
CEAD to be (1) any direct mechanical impact to the neck re- study population grouped according to disease status and
gion, (2) any impact to the head with indirect involvement of the prevalence of selected risk factors are presented in
the neck region, or (3) any mechanical activity causing greatly Table 1.
increased intrathoracic pressure (eg, heavy lifting) that had oc- After adjustment for the preselected variables, migraine
curred within 1 month before the first symptoms of dissec- without aura was significantly associated with the subgroup
tion. Traumatic events leading to medical examination or hos- of CEAD IS (OR, 1.74; 95% CI, 1.30-2.33), but we did not detect
pitalization were considered major, and all other events were any significant association between migraine with aura and
considered minor.9 Dissections occurring as an immediate con- CEAD IS (OR, 0.80; 95% CI, 0.49-1.29). Conversely, there was
sequence of a major trauma were excluded. a significant association with diabetes (OR, 3.84; 95% CI, 1.38-
For the purpose of the present analysis, patients in- 11.11), current smoking (OR, 1.38; 95% CI, 1.07-1.78), and hy-
cluded in the registry were dichotomized into 2 groups: IS due percholesterolemia (OR, 1.38; 95% CI, 1.03-1.88) with non-
to spontaneous CEAD (CEAD IS) and IS due to a cause other CEAD IS. A personal history of migraine was significantly
than CEAD (non-CEAD IS). Patients with non-CEAD IS were associated with the subgroup of CEAD IS only in men. Simi-
classified into etiologic subgroups according to the TOAST (Trial larly, although migraine without aura was associated with dis-
of Org 10172 in Acute Stroke Treatment) criteria.10 section in both sexes and it was independent of the patients
age, the magnitude of this association was higher in men than
Statistical Analysis in women (OR, 1.99; 95% CI, 1.31-3.04 vs OR, 1.53; 95% CI, 1.04-
Differences between the 2 subgroups (CEAD IS and non- 2.25) and in the subgroup of younger compared with older pa-
CEAD IS) were examined with the 2 test, an unpaired, 2-tailed tients (OR, 1.82; 95% CI, 1.22-2.71 vs OR, 1.55; 95% CI, 1.04-
t test, and the Mann-Whitney test, when appropriate. A cat- 2.31) (Table 2).
egorical (multinomial) logistic regression model was planned Finally, in the case-only analysis restricted to patients with
to examine the conditional effects of hypertension, diabetes, CEAD IS, we observed an increased prevalence of women with
smoking, hypercholesterolemia, and history of migraine and migraine compared with men with migraine, with or without
its subtypes (migraine without aura and migraine with aura) aura (62 [60.2%] vs 41 [39.8%], P .001), but did not find sig-
in the prediction of each subgroup, and was adjusted for age nificant differences in the vascular risk factor profile be-
and sex. To evaluate whether the magnitude of migraine ef- tween patients with and without migraine (Table 3).
fect may vary according to sex and age, we conducted the same The status of PFO carrier had no apparent influence on our
analysis separately for men and women and for 2 different findings. Although the prevalence of migraine, especially with
strata defined by median age. We additionally investigated aura, was higher in patients with PFO compared with those
whether, within the subgroup of patients with CEAD (case- without PFO (any migraine, 239 [30.3%] vs 389 [22.9%],
only analysis), the vascular risk factor profile differed be- P < .001; migraine without aura, 129 [16.3%] vs 286 [16.9%];
tween patients with migraine and patients without migraine. P = .74; migraine with aura, 110 [13.9%] vs 101 [6.0%], P < .001),
Finally, because of the suggested association between PFO and the exclusion of PFO carriers from the analysis (763 non-
migraine,11 we conducted subgroup analyses based on the in- CEAD IS and 26 CEAD IS) did not modify the association be-
dividual status of carrier or noncarrier of this cardiac inter- tween migraine categories, especially migraine without aura,
atrial septal abnormality. Results are given as odds ratios (ORs) and CEAD (any migraine, 89 [28.9%] vs 300 [21.6%], P = .006;
Table 2. Risk of Spontaneous CEAD According to Migraine Status in Sex and Age Categories
migraine without aura, 71 [23.1%] vs 215 [15.5%]; P = .001; mi- those without migraine, despite an expected preponderance
graine with aura, 16 [5.2%] vs 85 [6.1%], P = .53), which pro- of women among migraineurs.
vides further support for our observations.
Comparison With Other Studies
Most studies evaluating the association between migraine and
spontaneous CEAD have been limited to small cohorts, some
Discussion of which, but not all,12,13 provided evidence of association. A
In this large cohort study of patients with IS aged 18 to 45 years, pooled meta-analysis of these data suggested that a history of
we found a consistent association between migraine and spon- migraine increases the risk of spontaneous CEAD by 2-fold.2
taneous CEAD. This association persisted after adjustment for As stated by the authors, despite this evidence, the results of
traditional vascular risk factors, and it was apparent for the mi- the meta-analysis leave some remaining uncertainties. In par-
graine subtype without aura more than for migraine with aura, ticular, there are inconsistencies regarding the potential modi-
for men more than for women, and for the younger rather than fying effects of migraine aura status and sex, because of the
older age group. We also found no significant differences in risk low number of migraineurs with aura in individual studies, the
factor profile between patients with CEAD IS with migraine and small proportion of studies with sex-stratified data available,
Table 3. Comparison of Demographics and Vascular Risk Factors in CEAD IS Patients With Migraine
vs Without Migraine
No. (%)
Migraine No Migraine
Characteristic (n = 103) (n = 231) P Value
Age, mean (SD), y 36.9 (6.6) 37.7 (6.8) .33
Sex
Male 41 (39.8) 141 (61.0)
<.001
Female 62 (60.2) 90 (39.0)
Hypertension 20 (19.4) 57 (24.7) .29
Diabetes 1 (1.0) 3 (1.3) >.99
Hypercholesterolemia 28 (27.2) 42 (18.2) .06
Smoking 39 (37.9) 65 (28.1) .08
Dissected vessel
Internal carotid artery 64 (62.1) 125 (54.1)
Abbreviation: CEAD, cervical artery
Vertebral artery 29 (28.2) 88 (38.1) .21
dissection.
a
Multiple vessels 10 (9.7) 18 (7.8) a
More than 1 vessel involved.
and differences among the control groups, including IS con- vascular reactivity, has been consistently documented in the
trols in some studies and healthy participants in others. The 2 conditions. A genetic predisposition to the impaired endo-
results of our analysis are in line with those recently derived thelium-dependent vasodilatation observed in patients with
from the CADISP registry, the largest cohort study of patients CEAD and in those with migraine21,22 cannot be excluded, sug-
with CEAD.3 In that study, as in ours, migraine was associ- gesting that there could be a common generalized vascular dis-
ated with a higher risk of CEAD than of non-CEAD IS, and this order related to both entities. Conversely, in line with the re-
risk was especially evident for the migraine subtype without sults from the CADISP consortium, the possibility that people
aura. At variance with that study, we observed an age- with migraine have an increased propensity to develop CEAD
dependent association between migraine and CEAD, which was because of a nonfavorable vascular risk factor profile seems
stronger in the subgroup of the youngest patients. unlikely, based on our findings.
ences in group sizes might have introduced bias into the analy- phenotype is challenging due to the lack of objective mark-
sis of data. Fourth, since participants in this study were aged ers and uncertainty about the cause of the disease. Further-
18 to 45 years and white, with a documented acute cerebral more, as the recent large genetic studies on migraine have
infarct, generalizability to other populations might be lim- suggested, the phenotypes commonly used (migraine with-
ited. Finally, residual confounding cannot be definitively ruled out aura and migraine with aura) are probably not the most
out, as our data are observational. adequate to capture the heterogeneity of the many disease
subtypes.24
Implications of Findings
The results of our study support the findings of other case-
control studies2 linking migraine with an increased risk of
CEAD. At variance with most epidemiologic studies that
Conclusions
found an association between the migraine subtype with Our data support consideration of a history of migraine as a
aura and an increased risk of IS at a young age, our findings, marker for increased risk of IS caused by CEAD, as well as a pu-
as well as those of others, point toward the apparently para- tative susceptibility factor for CEAD, regardless of its clinical
doxical conclusion that, at least for CEAD, the most frequent features. This finding emphasizes the need for further analy-
cause of early-onset brain ischemia, this risk is mainly ses to investigate the nature and mechanisms of elevated risk
driven by the migraine subtype without aura. However, for in migraineurs and to elucidate whether this risk applies to only
complex diseases, such as migraine, identification of the specific subsets of patients with migraine.
ARTICLE INFORMATION (Sessa, Giossi); Stroke Center, Dipartimento di Acquisition, analysis, or interpretation of data: All
Accepted for Publication: November 21, 2016. Neurologia, Ospedale Sacro Cuore Negrar, Verona, authors.
Italia (Adami); Stroke Unit, Unit Operativa Drafting of the manuscript: De Giuli, Pezzini.
Published Online: March 6, 2017. Neurologia, Azienda Ospedaliera Carlo Poma, Critical revision of the manuscript for important
doi:10.1001/jamaneurol.2016.5704 Mantova, Italia (Silvestrelli, Lanari); Stroke Unit, intellectual content: All authors.
Author Affiliations: Dipartimento di Scienze Istituto di Ricerca e Cura a Carattere Scientifico Statistical analysis: Grassi, Pezzini.
Cliniche e Sperimentali, Clinica Neurologica, Fondazione Istituto C. Mondino, Pavia, Italia Obtained funding: Lodigiani, Pezzini.
Universit degli Studi di Brescia, Brescia, Italia (Cavallini); Neurologia dUrgenza e Stroke Unit, Administrative, technical, or material support:
(De Giuli, Costa, Poli, Morotti, Caria, Padovani, Istituto di Ricerca e Cura a Carattere Scientifico De Giuli, Pezzini.
Pezzini); Dipartimento di Scienze del Sistema Humanitas Research Hospital, Rozzano-Milano, Study supervision: Pezzini.
Nervoso e del Comportamento, Unit di Statistica Italia (Marcheselli, Coloberti); Unit Operativa Conflict of Interest Disclosures: None reported.
Medica e Genomica, Universit di Pavia, Pavia, Italia Complessa Neurologia, Ospedale C Foncello, Unit
(Grassi); Centro Trombosi, Istituto di Ricerca e Cura Locale Socio Sanitaria 9, Treviso, Italia (Bonifati); Funding/Support: The Italian Project on Stroke in
a Carattere Scientifico Humanitas Research Unit Operativa Complessa Neurologia, Ospedale Young Adults is supported by a grant from the
Hospital, Rozzano-Milano, Italia (Lodigiani, Valduce, Como, Italia (Checcarelli); Unit Operativa Associazione per la Lotta alla Trombosi e alle
Ferrazzi); Stroke Unit, Azienda Ospedaliera Neurologia, Azienda Ospedaliera Ospedale Malattie Cardiovascolari.
SantAndrea, Universit La Sapienza, Roma, Italia SantAnna, Como, Italia (Tancredi); Neurologia, Role of the Funder/Sponsor: The Associazione per
(Patella, Spalloni, Di Lisi, Rasura); Unit di Azienda Ospedaliera Universitaria Pisana, Pisa, Italia la Lotta alla Trombosi e alle Malattie Cardiovascolari
Neurologia, Arcispedale Santa Maria NuovaIstituto (Chiti); Unit Operativa Complessa Neurologia, had no role in the design and conduct of the study;
di Ricerca e Cura a Carattere Scientifico, Reggio AUSL Romagna, Ravenna, Italia (Lotti); Unit collection, management, analysis, and
Emilia, Italia (Zedde, Malferrari); Dipartimento di Operativa Recupero e Rieducazione Funzionale, interpretation of the data; preparation, review, or
Neuroscienze, Riabilitazione, Oftalmologia, Istituto di Ricerca e Cura a Carattere Scientifico approval of the manuscript; and decision to submit
Genetica e Scienze Materno-Infantili, Universit di Fondazione Don Gnocchi, Rovato, Italia (Del Zotto); the manuscript for publication.
Genova, Genova, Italia (Gandolfo, Massucco); Unit di Neurologia, Ospedale S. Andrea, La Spezia, Group Information: The Italian Project on Stroke in
Stroke Unit, Clinica Neurologica, Nuovo Ospedale Italia (Giorli); Stroke Unit, Unit Operativa Clinica Young Adults (IPSYS) Investigators are listed in the
Civile S. Agostino Estense, Azienda Unit Sanitaria Neurologia, Istituto di Ricerca e Cura a Carattere eAppendix in the Supplement.
Locale, Modena, Italia (Zini, Simone); Unit di Scientifico S. Raffaele, Milano, Italia (Giacalone);
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