Preexisting migraine history in patients treated with intravenous tissue plasminogen activator is a predictor for negative diffusion-weighted imaging, which is associated with stroke mimic status, according to a recent article in the Journal of Stroke and Cerebrovascular Diseases.

Symptoms of neurologic deficits that occur in 10% of patients with migraine, along with about 30% of emergency room suspected strokes, are often misdiagnosed. The researchers sought to find predictors in patient demographics; stroke characteristics; and clinical comorbidities, including migraine, epilepsy, psychological disturbance, diabetes, hypertension, atrial fibrillation, and so on, which allow for the prediction of stroke mimics. With a retrospective study of 47 negative diffusion-weighted imaging cases and 228 positive diffusion-weighted imaging controls, the researchers analyzed their variables for statistical significance. The cases and controls had all been previously treated with intravenous tissue plasminogen activator on suspicion of a stroke diagnosis.

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Using a multivariate logistic regression model, the researchers found that migraine history was the only significant predictor of a negative diffusion-weighted imaging (P =.017). Additionally, the researchers found that atrial fibrillation was significantly more prevalent in the positive diffusion-weighted imaging controls (P =.017) and that the negative diffusion-weighted imaging cases had a higher, but not significant National Institutes of Health Stroke Scale Score than the positive diffusion-weighted imaging controls (12.8 vs 9.5, P =.298). All other variables were found to have insignificant differences between the groups.

The main limitation of this study was that it was a single center study of retrospective design. Additionally, the authors mentioned that a subgroup of patients with migraine with auras was not included, which could have been relevant to the characteristics of a stroke mimic and is an area for future research.

The researchers concluded that migraine history is a potential predictor for stroke mimic status and holds useful application in acute evaluation of younger patients without traditional risk factors. However, it “should not preclude treatment with intravenous tissue plasminogen activator considering the outcomes of missed strokes and low complication risk of [intravenous tissue plasminogen activator] in these patients.”


Lima J, Mehta T, Datta N, et al. Migraine history: a predictor of negative diffusion-weighted imaging in IV-tPA-treated stroke mimics [published online August 8, 2019]. J Stroke Cerebrovasc Dis. doi: 10.1016/j.jstrokecerebrovasdis.2019.06.040