Locally Asymptomatic Ischemic Stroke May Present as Migraine Aura

older man with headache
older man with headache
Local ischemia after an acute ischemic stroke may trigger a widely migrating cortical wave of spreading depolarization, which may present as migraine aura.

Acute ischemic stroke can present as migraine aura so that a diagnosis of stroke cannot be definitively excluded, even in patients with a history of migraine, according to a study published in the Journal of Clinical Neuroscience.

Migraine aura does not usually indicate cerebral ischemia, but patients with a migraine diagnosis have an elevated risk for stroke that cannot be attributed to traditional risk factors. At the Royal Adelaide Hospital in Adelaide, Australia, between March 2012 and November 2016, 14 patients presenting with migraine aura symptoms (a slowly evolving syndrome of visual symptoms, slowly evolving dysphasia, or spreading paresthesia) who showed evidence of acute infarction on MRI were prospectively identified.

Of the total patients, 10 first had symptoms that could be attributed to the ischemic lesion shown on MRI and then experienced migraine aura symptoms, and 4 had a locally asymptomatic acute cerebral ischemia that presented only with symptoms of migraine aura.  In all participants, symptoms of migraine aura were not directly attributable to the vascular lesion on MRI.  

Symptoms of migraine aura were classified as sensory (n=5), visual (n=6), dysphasia (n=5), or mixed phenomena (n=2).  Of the total 14 patients, 7 had a history of migraine and 5 had a history of migraine aura. In 7 patients, stroke etiology could be identified, and the other 7 were diagnosed with an embolic stroke of undetermined source. Patent foramen ovale could be identified in 80% of patients with embolic stroke of undetermined who had undergone transesophageal echocardiograms.

Study investigators conclude that, “this cohort of patients with ischaemic stroke manifesting symptomatically as migraine aura demonstrates an important clinical phenomenon which is under-recognised and has important clinical implications. An ischaemic precipitant cannot be definitively excluded when patients present with migraine aura, even (or perhaps especially) when there is a past history of migraine aura. The threshold for definitive tissue imaging of such patients with MRI should be low.”

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Waters MJ, Cheong E, Jannes J, Kleinig T. Ischaemic stroke may symptomatically manifest as migraine aura. J Clin Neurosci. doi: 10.1016/j.jocn.2018.07.017