Hypertensive disorders partly explain maternal stroke risk linked to migraines
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Women with migraines had an elevated risk for maternal stroke that may also be related to hypertensive disorders, according to a research letter published in JAMA Neurology.
“The findings suggest that by managing hypertension and preeclampsia in pregnancy, approximately one-quarter of the cases of stroke attributable to migraines could potentially be prevented,” Gretchen Bandoli, PhD, assistant professor in the department of pediatrics at the University of California, San Diego, told Healio.
Researchers analyzed data from a retrospective California birth cohort of 3 million singleton live births that occurred between 2007 and 2012. They identified conditions such as migraine, stroke and hypertensive disorders including preeclampsia through ICD codes.
Among the cohort, 26,440 women were diagnosed with migraine, which equated to 914 of every 100,000 deliveries. There were also 843 women who had a stroke, or 29 of every 100,000 deliveries. Ischemic strokes accounted for 58% of the stroke events.
Compared with women without migraines, those with migraines were more likely to have private insurance (61.2% vs. 46.2%), be non-Hispanic white (41% vs. 25.9%), have preexisting or gestational diabetes (11.9% vs. 9.2%) and have obesity (30.5% vs. 18.9%). In addition, these women were also more likely to use tobacco (8.9% vs. 4.5%), alcohol (1.5% vs. 0.4%) or drugs (6.6% vs. 1.6%), and to have a mental health disorder including depression (9.2% vs. 1.2%), bipolar disorder (4.8% vs. 0.6%) or anxiety disorder (9.5% vs. 1.3%).
Women who had migraines during pregnancy were more likely to have a stroke during pregnancy or delivery (0.5% vs. 0.01%; adjusted RR = 6.8; 95% CI, 4.7-9.8), hypertensive disorder (15.1% vs. 7%; aRR = 1.6; 95% CI, 1.6-1.7) or a stroke postpartum (0.05% vs. 0.01%; aRR = 2.1; 95% CI, 1.2-3.7) compared with women without migraines.
Hypertensive disorders explained 21% of the risk for stroke during pregnancy and delivery and 27% of the postpartum stroke risk in a mediation analysis. Preeclampsia contributed to most of the excess risk linked to hypertensive disorders in stratified analyses.
“Cardiologists should continue to counsel on the importance of well-controlled blood pressure, particularly before and during pregnancy,” Bandoli said in an interview. “Hypertension only accounted for one-quarter of the excess risk of maternal stroke associated with migraine, indicating there are other risk factors that we have not yet quantified. In the perinatal period, maternal stroke, although rare, has a tremendous amount of associated morbidity. Continuing to study modifiable risk factors is warranted.”
Perspective
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Islam Y. Elgendy, MD
Migraine headaches have been linked to CV events, particularly stroke. This association also has been demonstrated among pregnant women. Hypertensive disorders of pregnancy have been thought to mediate this association; however, this has never been quantified.
Using an administrative database from California, the authors showed that migraine was associated with maternal stroke as shown in our studies. They also found that approximately one-quarter of the maternal strokes associated with migraine are linked to hypertensive disorders.
This study confirms the importance of identification and careful management of hypertensive disorders during pregnancy, especially among pregnancy women with migraine.
Future research should focus on identifying therapies, which could help reduce the risk for stroke.
It is important to highlight that some studies have suggested that migraine during pregnancy could be misclassified with preeclampsia from administrative databases. Further, the study relies on administrative codes of stroke, which only have been validated among elderly patients and not among young pregnant women.
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