Increased Risk of Atrial Fibrillation in Migraine with Aura

Souvik Sen MD, MS, MPH, FAHA, Professor and Chair, Department of Neurology, University of South Carolina School of Medicine

Souvik Sen MD, MS, MPH

A large U.S. cohort study found that migraine with aura is associated with an increased risk of incident atrial fibrillation (AF), which may potentially lead to ischemic strokes.

After adjusting for multiple variables like age, sex, hypertension, and smoking status, among other factors, individuals with migraine with visual aura demonstrated a 39% significant increase in the risk of incident AF when compared with those who experienced migraine without aura and a 30% increased risk when compared with individuals who did not experience headache (P = .004). This finding has important clinical implications and might provide a better understanding of the role of AF in the migraine-stroke link. The researchers suggest that a randomized clinical trial may help determine if individuals with migraine with visual aura may benefit from AF detection and subsequent anticoagulation or antiplatelet therapy as a primary stroke prevention strategy.

“Epidemiological studies show that migraine with aura is associated with increased risk of stroke particularly in a young population,” Souvik Sen, MD, MPH, professor in the department of neurology, University of South Carolina, told NeurologyLive. “In the past we noted the association was particularly strong between migraine with aura and cardioembolic stroke subtype. AF or “irregular heartbeat” is the commonest cause for cardioembolic ischemic stroke. Therefore, we evaluated the potential association between migraine with visual aura and incident AF in the Atherosclerosis Risk in Communities (ARIC) cohort based in the United States. If migraine with aura is associated with AF, then AF may lead to thromboembolism into the cerebral blood vessels leading to ischemic strokes.”

Sen and colleagues used the longitudinal, community-based ARIC cohort study, which included 11,939 individuals (mean age, 60 ± 5.7 years; 56% women) with no history of AF or stroke, to analyze atherosclerosis causes and clinical outcomes in 4 U.S. communities. Participants were interviewed for migraine history in 1993­­—1995 and were followed for AF incident through 2013. In total, 426 individuals experienced migraines with visual aura, 1090 experienced migraine without visual aura, 1018 experienced non-migraine headache, and 9405 experienced no headache.

Of the total population who met relevant inclusion criteria, 1516 individuals reported migraine and 9405 reported no headache. The non-headache group was significantly older (mean age 60.4 years) compared to the group with migraine headache (mean age 58.4 years) (P <.0001). Additional notable differences included the non-headache group having a significantly higher proportion of men, African American individuals, those with diabetes, smokers, alcohol users and those with coronary artery disease compared to the migraine headache group (P <.05). The migraine group had a higher proportion of hypercholesterolemia (P <.0001) and higher levels of total cholesterol compared to the no-headache group (P = .01).

During the 20-year follow-up period, incident AF was reported in 232 (15%) of 1516 individuals with migraine and 1623 (17%) of 9405 individuals without headache. Additionally, incident AF was noted in 80 (18%) of 440 with migraine with visual aura and 152 (14%) of 1105 migraine without visual aura subjects.

The study showed significant interaction with age and sex. Men who experienced migraine with aura had an 89% increased risk of AF while women with aura showed no increase in risk, compared to individuals who did not experience headache. The results need to be verified in additional studies but appear to be consistent with those reported in other AF studies. Similarly, individuals aged 60 years or older who experienced migraine with aura showed an increased risk of AF while those younger than 60 years of age did not. This difference could be explained by the significant differences noted in baseline characteristics, the researchers added. The stroke incidence rate in the migraine with aura group (4.1/1000 person-years) was about two times greater than that noted in migraine without aura (2.07/1000 person-years) and higher than noted in the no-headache group (3.02/1000 person-years).

The research suggests that AF may play a role in stroke in those with migraine with visual aura, Sen concluded. Additional research is needed to determine if those with migraine with visual aura should be screened for AF.

“Migraine with visual aura (MA) has been associated with an increased risk of stroke, specifically cardioembolic ischemic stroke (CES),” Sen adds while discussing additional questions this research opens up. “Among various pathophysiological mechanisms postulated for the association between MA and incident AF, autonomic dysfunction among the population with MA may play a key role. This association has not been studied in any large cohort study.”

REFERENCE

Sen S, Androulakis XM, Duda V, et al.

Migraine

with visual aura a risk factor for incident atrial fibrillation: a cohort study. Neurology 2018;91.

doi

: 10.1212/WNL.0000000000006650.