Migraine and Cerebrovascular Stroke: Risk Factors and Outcome

Transcription

1 Original Article Elwan et al.: Migraine and CVS Migraine and Cerebrovascular Stroke: Risk Factors and Outcome Mohamed E. Elwan, Ahmad M. Elshereef, Rasha A. Elkapany, Hosna S. Soliman Department of Neuropsychiatry, Minoufiya University; Egypt ABSTRACT Background: The relationship between migraine and cerebro-vascular stroke is extremely complex and bidirectional. Objective: This study aimed to determine whether migraine is a risk factor for stroke; the characteristics, degree of disability and prognosis of acute stroke in patients with migraine. Methods: This study was carried out on 0 patients suffering from stroke. They were compared with another 0 persons as a control group. Each group was divided into two subgroups (migrainous and non-migrainous). Each patient was subjected to thorough medical and neurological history taking, complete general and neurological examination, routine work up for stroke risk factors, and CT scan brain. Severity of stroke was assessed by using clinical outcome scales {National Institute of Health Stroke Scale (NIHSS) and Barthel Index}; at onset and every two weeks for eight weeks. Results: There was a statistically significant difference between stroke patients and control group regarding history of migraine (25% versus 2.5%), but there was no significant difference regarding type of migraine. History of migraine was associated with increased risk of stroke with no significant difference regarding type of stroke (ischemic or hemorrhagic) and type of migraine. There was a statistically significant difference between migranous and non-migranous stroke patients as regard outcome. Migrainous stroke patients show better outcome than non-migrainous at different follow up visits regarding results of Barthel index but not with NIHSS score. Conclusion: History of migraine was associated with increased risk of stroke. However; migrainous stroke patients showed better outcome than non- Migrainous. (Egypt J Neurol Psychiat Neurosurg. 200; 7(2): 337-3) Key Words: migraine, stroke, outcome INTRODUCTION Migraine is a painful neurological condition, of which the most common symptoms is an intense and disabling episodic headache on one or both sides of the head. It is often accompanied by photophobia, phonophobia and nausea and may be preceded by aura. Both migraine and stroke are associated with altered cerebral blood flow, focal neurological deficits, and headache 2. The relationship between migraine and stroke encompassing at least issues: migraine as a cause of ischemic stroke (migrainous infarcts), migraine and ischemic stroke sharing a common cause (symptomatic migraine), migraine attacks triggered by cerebral ischemia, and migraine as a risk factor for ischemic stroke. There seems to be no sex difference regarding the first 3 issues in contrast to the fourth issue, migraine as a risk factor for ischemic stroke, which seems to apply mostly to young women 3. Migrainous infarcts are said to be frequent causes of ischemic stroke in the young, its annual rate has been estimated at 3.36 cases per 00,000. Stroke appears to be most strongly associated with migraine with aura. Recent cross sectional study provided evidence that patients with migraine have increased risk of sub- clinical infarcts. Correspondence to Ahmad M. Alshereef, Department of Neurology, Minoufiya University; Egypt. Tel.: alshereef hotmail.com. Ischemic induced migraine attacks were more frequent than migrainous infarctions 5. Aim of the work: This study aimed to determine whether migraine is a risk factor for stroke; the characteristics, degree of disability and prognosis of acute stroke in patients with migraine in comparison with patients without migraine; and to study the association of migraine to known stroke risk factors. PATIENTS AND METHODS Patients and control: This study was carried out on 0 consented patients suffering from first ever cerebro-vascular stroke. They were 9 males and 2 females and their age ranged from 5-70 years with mean age 60.00±.7. They were randomly selected from neurology department of Minoufiya University Hospital in the period from March to December, They were compared with 0 consented control patients selected randomly from orthopedic department of Menoufiya University Hospital. They were 9 males and 2 females and their age ranged from -68 years with mean age 58.7±.0. Exclusion Criteria includes: - Patients with previous history of cerebro-vascular stroke or transient ischemic attacks (TIAs), 2- Patients with other neurological disorders. Egypt J Neurol Psychiat Neurosurg. April 200 Vol 7 Issue 2 337

2 Both groups (patients and control) were divided according to history of migraine into migrainous and non-migrainous. Methods: both patients and control groups were subjected to: - Thorough medical and neurological history taking including their history of vascular risk factors. 2- Interview about their history of headache using headache sheet 6. Migraine patients were identified according to the IHS criteria (200) Complete neurological examination. - Laboratory investigations for stroke risk factors as complete blood picture, serum glucose level, serum creatinine, liver function tests, serum uric acid and lipid profile. 5- ECG, Echocardiography and carotid duplex. 6- CT brain at the onset of stroke (first 72 hours) to determine site and size of the lesion that was repeated 3 days later if the lesion not appeared at the onset. 7- Stroke patients were subjected to clinical outcome scale of National Institute of Health Stroke Scale (NIHSS) 8 and functional outcome scale of Barthel Index of Activities of Daily Living (ADL) 9, at onset of stroke, and every two weeks for eight weeks to determine the degree of disability and prognosis of acute stroke in patients with migraine in comparison with patients without migraine. Statistical Method Data was collected, tabulated and analyzed by SPSS version.0 statistical package (SPSS Inc. Chicago, Illinois, USA). Quantitative data expressed as mean and standard deviation (X ± SD). Student t-test was used to compare two groups of normally distributed variables and Mann-Whitney (U test) for non normally distributed variables. Qualitative data expressed as number and percentage and analyzed by Chi-square test with or without Yale's Continuity Correction when appropriate. Level of significance was set as P-value <0.05. RESULTS Regarding history and type of migraine; 0 out of 0 (25%) stroke patients had history of migraine (out of them (0%) patient had migraine with aura and 9 patients (90%) had migraine without aura), while in control group only 5 (2.5%) persons had history of migraine non of them had migraine with aura. These differences was statistically significant (P<0.05) as regard history of migraine only (Table ). Frequency and duration of migraine were higher in stroke than control group with no significant difference. As regard triptan use, no significant difference was noticed between migrainous stroke patients and migrainous control group (Table2). As regard side of unilateral headache in relation to side of lesion in C.T brain in migrainous stroke patients; 5 (50%) patients had bilateral headache, 5 (50%) patients had unilateral headache out of them 3 (30%) on right side and 2 (20%) on left side (Table 3). The most important risk factors in migrainous stroke patients were contraceptive pills administration reported 5 (50%) patients, diabetes mellitus in (0%) patients, and hypercholesterolemia, hyperuricemia, while family history of migraine and stroke in 3 (30%) patients for each. The most important risk factors nonmigrainous stroke patients; were hypertension in 5 (50%) patients, smoking and hyperuricemia in (36.7%) patients, diabetes mellitus in 0 (33.3%) patients, and cardiac diseases in 9 (30%) patients, while contraceptive pills and family history of migraine were only a risk factor in (3.3%) patients and (3.3%) patient respectively. There was a significant difference between the two groups as regard contraceptive pills (P <0.00), hypercholesterolemia, and family history of migraine only (P <0.05) (Table ). The prevalence of infarction was higher than hemorrhage in both migrainous and non-migrainous stroke patients, with ratio of infarction to hemorrhage is 9 to. Results also showed that about 50% of migrainous stroke patients had affection of posterior cerebral artery (PCA) in comparison to 3.3% in nonmigrainous stroke patients. Middle cerebral artery (MCA) was affected in about 0% of migrainous stroke patients while it was affected in about 83.% of nonmigrainous stroke patients. As regard site of the lesion, it showed a significant difference (P<0.05) only in thalamic lesions which was higher in migrainous stroke patients (Table 5). Figure () and (2): showed the difference in NIHSS score and Barthel Index scale between migrainous (A) and non-migrainous (B) stroke patients at onset and every two weeks for eight weeks. It showed that the outcome of migrainous stroke patients was better than non-migrainous patients at different follow up periods that it was significant (P<0.05) as regard functional daily activities that assessed by Barthel Index scale, but not significant as regard NIHSS. 338 Egypt J Neurol Psychiat Neurosurg. April 200 Vol 7 Issue 2

3 Table. History of migraine and its type among the studied groups. Studied groups Total Variables Stroke Group Control Group X² P-value Number Percentage Number Percentage Number Percentage History of migraine: < 0.05* Type of migraine: With aura Without aura X² chi square * Statistically significant at p< > 0.05 Table 2. Difference between stroke and control migrainous subjects as regards use of Triptans, frequency and duration of migraine attacks per year. Variables Number (n=0) Stroke Migrainous Percentage Number (n=5) Control Percentage X² P- value Use of Triptans > 0.05 t- Frequency of migraine per year (X±SD) 7.6± ±9 test > Duration of migraine per years (X±SD) 6.7± ± > 0.05 SD standard deviation, X ² chi square Table 3. Side of unilateral headache in relation to side of lesion in C.T in migrainous stroke patients. Variables Headache on same side of CT lesion Headache on opposite side of CT lesion Total Number Percentage Number Percentage Number Percentage Z-test p- value noisel eht fo edis > 0.05 CT computerized tomography Table. Distribution of risk factors for cerebrovascular stroke in stroke patients. Variables With migraine (No=0) Number Stroke patients Without migraine (No=30) Total Percentage Number Percentage Number Percentage X² P-value Smoking: > 0.05 Hypertension: > 0.05 Cardiac disease: > 0.05 Diabetes mellitus: > 0.05 Hypercholesterolemia: < 0.05* Hyperuricaemia: > 0.05 Contraceptive pills administration: < 0.00** Family history of migraine < 0.05* Family history of stroke > 0.05 Total X² chi square * Statistically significant at p<0.05** Statistically significant at p<0.0 Egypt J Neurol Psychiat Neurosurg. April 200 Vol 7 Issue 2 339

4 Table 5. Distribution of C.T results among migranous and non-migranous stroke patients. C.T findings Type of lesion: Infarction Hemorrhage Side of lesion: Right Left Size of lesion: Small Medium Large Site of lesion: Basal ganglion With migraine Stroke patients Without migraine Total Number Percentage Number Percentage Number Percentage Test of significa nce P-value χ² = 0.0 > 0.05 χ²= 0.0 > 0.05 χ² = 2. > 0.05 Frontal > 0.05 Internal capsule > 0.05 Fronto- parieto- temporal > 0.05 Midbrain Z- test 0.60 > > 0.05 Cerebellum > 0.05 Thalamus < 0.05* Occipital > 0.05 Affected artery: MCA ACA PCA χ² = 7. > 0.05 Total ACA anterior cerebral artery, MCA middle cerebral artery, PCA posterior cerebral artery * Statistically significant at p<0.05 A) NIH score in migrainous stroke patients at different follow up visits 00 B) NIH score in nonmigrainous stroke patients at different follow up visits at onset 2 weeks weeks 6 weeks 8 weeks Mild Moderate Severe -20 at onset 2 weeks weeks 6 weeks 8 weeks Mild Moderate Severe -0 Figure. Difference in NIHSS score among migrainous (A) and non-migrainous, 30 Egypt J Neurol Psychiat Neurosurg. April 200 Vol 7 Issue 2

5 (B) stroke patients at onset and every two weeks for eight weeks. A) Barthel index in migrainous stroke patients at different follow up visits B) Barthel index in nonmigrainous stroke patients at different follow up visits at onset 2 weeks weeks 6 weeks 8 weeks Mild Severe Moderate Independent 0-20 at onset 2 weeks weeks 6 weeks 8 weeks Mild Severe Moderate Independent Figure 2. Difference in Barthel index among migrainous (A) and non-migrainous, (B) stroke patients at onset and every two weeks for eight weeks. DISCUSSION Many studies have suggested a complex bidirectional relation between migraine and stroke, including migraine as a cause of stroke, migraine as a risk factor for or as a consequence of cerebral ischemia, and migraine and cerebral ischemia sharing a common cause. In this study, 25% of patients who had a stroke reported a personal history of migraine compared to 2.5% in control group. This is in agreement with Agostoni and Rigamonti 2 who reported that the risk of stroke doubled or slightly more than doubled in patients with migraine as the adjusted relative risk (RR) of clinical stroke in migraine subjects ranged from.7 to Results of this study differs from the results reported by Etminan et al. 0, who found that, the prevalence of migraine in the whole group of patients with ischemic stroke was not different from that in the matched controls, so that migraine was not a risk factor for stroke. Also Milhaud et al., who studied the characteristics of patients with ischaemic stroke and migraine found that, the prevalence of migraine in patients with ischaemic stroke (3.7%) was lower than that reported in the controls (6% in men and 7.6 in women). Possible explanations of our results include that vasospasm of the brain arteries and regional cerebral blood flow changes are present among patients with migraine, leading to 30 to 0% reduced flow in the affected vascular territories. Although there is evidence that the local oxygenation in the brain is adequate during migraine attacks, a combination of vasospasm and activation of the clotting system may lead to an increased risk of embolism, thrombosis, or ischemia. Friberg et al. 2 suggested that increased local changes during migraine attacks, including neuronal activation and associated neurogenic inflammation, may contribute to increased risk of brain ischemia. Sixty percent of migrainous stroke patients in this study were female, 0% were males with male to female ratio 2 to 3. This result was in line with Milhaud et al. who found that, 6% of migrainous stroke patients were males and 7.6% were females. This difference in sex could be due to the fact that the prevalence of migraine is higher in female as around 25% of women experience a migraine at least once a year, compared with fewer than 0% of men 3. With respect to the age, in this study, mean age in migrainous stroke patients was lower than mean age in non-migrainous stroke patients (5.2±8.7 versus 59.7±0.9 respectively), but the difference was statistically insignificant between both groups. These findings are coincident with Milhaud et al., who found that, in the subgroup of population aged 5 and older, the prevalence of migrainous was lower than that in the general population, suggesting that, brain infarcts after 5 years may be less frequent in migrainous than in non migrainous. Buring et al. conducted a large population-based studies on both men and women of all ages have suggested that, migraine is a risk factor for brain infarct, but that the risk decreases with age. Egypt J Neurol Psychiat Neurosurg. April 200 Vol 7 Issue 2 3

6 A potential explanation by which migraine may be associated with ischemic stroke in younger women but not for the older age group may be that other major risk factors for ischemic stroke acquire greater importance with increasing age or interact with the mechanism by which migraine may lead to stroke. This hypothesis is supported by the finding that in the absence of classic cardiovascular risk factors, migraine remained associated with ischemic stroke in our data and other studies. However Merikangas et al. 5 reported no increased risk of ischemic stroke among the elderly (age 60 and older) with a history of migraine. In this study, one patient in stroke group has migraine with aura whether rest of patients had simple migraine without aura. This was in agreement with results of Chang et al. 6, who investigated the extent to which simple or classical migraine predispose to all stroke (combined ischemic, hemorrhagic and unclassified stroke); and found increased risk among participants with migraine without aura. Also, in the study of Tzourio et al. 7, who studied 37 patients with migraine, 3 had migraine without aura, 5 had migraine with aura, and could not be classified due to uncertainty by the patient. On contrary, Leah et al. 8 studied 386 women aged 5 to 9 years with first ischemic stroke and 6 age and ethnicity-matched controls. Based on their responses to a questionnaire on headache symptoms, subjects were classified as having no migraine, migraine without, or migraine with aura. They found that, overall and subgroup analyses did not indicate any association between migraine without aura and stroke but prevalence of migraine with aura is two folds more in stroke than control patients. As regard frequency and duration of migraine, migrainous stroke patients had longer duration and more frequency than migrainous control patients. These results are inconsistent with Tzourio et al. 7, who reported mean frequency 2.6±3.2 in migrainous stroke patients vs..8±.5 in migrainous control patients. Also, Donaghy et al. 9 conducted a study on 86 cases of ischemic stroke and 2 controls reported that, the adjusted risk of ischemic stroke was significantly associated with () migraine of more than 2 years duration, (2) initial migraine with aura, and, (3) particularly if attacks were more frequent than 2 times per year. In respect to side of the migrainous headache, 5 (50%) had bilateral headache, 5 (50%) had unilateral headache (with 3 (30%) of them on the side of cerebral lesion and 2 (20%) on the opposite side). These results were inconsistent with results of Peatfield 20, who found that, 55 out of patients had headache on the same side of lesion and 20 patients on the opposite side. In this study, use of triptans reported only in 3 (30%) of migrainous stroke patients and in 2 (0%) of migrainous control patients. This is in agreement with results of Hall et al. 2, who stated that, out of 63,575 migraine patients (2.5%) was prescribed a triptan. The larger group of migraine patients not prescribed a triptan had an increased risk of stroke. These results could be explained by the fact that sumatriptan has no direct effect on platelet aggregation; it has even been shown that triptans can normalize the increased platelet activation of patients with migraine with aura 22. Also triptans have no adrenergic activity; that is why it is unlikely that these drugs could induce marked vasoconstriction and decreased arterial vessel wall distensibility in extracerebral vessels 23. As regard stroke risk factors, in this study, there was no significant difference between migrainous and non-migrainous stroke patients except for hypercholesterolaemia which show significant difference, and contraceptive pills administration which show highly significant difference in migrainous in comparison to non-migrainous patients. These findings are in line with that of Kurth et al. 2, who reported that, compared with participants who did not report ever having migraine, women who reported migraine with aura were younger, more likely to have reported a history of cholesterol level of >20 mg/dl, and to have used oral contraceptives, and to be currently on hormone therapy. Chang et al. 6 found that, regarding the risk of ischemic and hemorrhagic stroke among women with and without a history of migraine associated with: use of oral contraceptives; a history of high blood pressure and smoking, the coexistence of each of these factors has a greater than multiplicative effect on the odds ratios for ischaemic stroke associated with a history of migraine, although the apparent synergy was only statistically significant for smoking. As regard CT findings, there was no statistically significant difference between migrainous and nonmigrainous stroke patients regarding side, size and type of lesion. In migrainous group prevalence of infarction was higher and there was predominance of posterior cerebral artery (PCA) affection 5 (50.0%) and thalamic lesions were the most frequent site involved. This was in agreement with Milhaud et al., who found that, Stroke in the posterior circulation, especially in the PCA territory, is more often associated with headache than stroke in the anterior circulation and the infarct occurs more commonly in the thalamus. In the study of Hoekstra et al. 25 infarction involved the occipital lobe in of the patients with migraine, whereas this occurred in patients with non migrainous. This could be explained by the fact that the occipital cortex may be the most vulnerable to infarcts because of both its neuronal and arterial characteristics, being the site where the spreading depression originates and being supplied by the posterior cerebral artery, the most densely innervated of the major vessels arising from the circle of Willis 26. According to results of NIHSS score in different follow up visits in this study, there was no statistically significant difference between migrainous and non- 32 Egypt J Neurol Psychiat Neurosurg. April 200 Vol 7 Issue 2

7 migrainous stroke patients, but according to Barthel index there was no statistically significant difference between migrainous and non-migrainous stroke patients at onset and at 8 weeks, but there was statistically significant difference at 2 weeks, weeks and 6 weeks. This was in agreement with Milhaud et al. who mentioned a hint in their data that migraineurs may more frequently have a favorable outcome at month than non migraineurs approximately in younger and older patients. Another study done by Waters et al. 27 showed that, in a 2-years follow-up of a population of,30 women, patients without headache had a higher mortality than those with headache or migraine. The outcome at weeks was favorable in 72% of migraineurs compared with 63% of non migrainous control subjects. This could be explained by the fact that stroke in migrainous patients occur usually in younger age and on top of less atherosclerotic vessels hence the better recovery on both clinical and cellular level 28. In Conclusion, a personal history of migraine was associated with increased risk of cerebro-vascular stroke with no significant difference regarding type of stroke (ischemic and hemorrhagic) and type of migraine (with or without aura). The outcome of stroke was favorable in migrainous compared with non migrainous. Also, coexistence use of oral contraceptive pills had more than multiplicative effects on risk for cerebrovascular stroke. REFERENCES. Silberstein SD, Lipton RB, Goadsby PJ. Headache in clinical practice. 2nd ed. London; New York: Taylor & Francis; Agostoni E, Rigamonti A. Migraine and cerebrovascular disease. Neurol Sci. 2007; 28: S Adams H, Adams R, Del Zoppo G, Goldstein LB. Guidelines for the early management of patients with acute ischemic stroke: Guidelines updated a scientific statement from the stroke council of the American Heart Association/American Stroke Association. Stroke. 2005; 36 (): Bousser MG, Good J, Silberstein S. Headache associated with vascular disorders. In: Silberstein SD, Lipton RB, Dalessio DJ, editors. Wolff s Headache. Volume, 7 th edition. New York, NY: Oxford University Press; 200. p Rothrock J, North J, Madden K, Lyden P, Fleck P, Dittrich H. Migraine and Migrainous Stroke: Risk Factors and Prognosis. Neurology. 993; 3: Bottos S, Dewey D. Perfectionists' Appraisal of Daily Hassles and Chronic Headache. Headache. 200; : Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders, 2 nd edition. Cephalagia. 200; 2 Suppl : Adams HP Jr, Davis PH, Leira EC, Chang KC, Bendixen BH, Clarke WR, et al. Baseline NIH stroke scale score strongly predicts outcome after stroke. A report of the trial of org.072 in acute stoke treatment (TOAST). Neurology. 999; 53: Wyler T, Sveen U, Bautz-Hoter E. The Barthel Index one year after stroke: comparison between relatives and occupational therapist's scores. Aging. 995; 2: Etminan M, Takkouche B, Isorna FC, Samii A. Risk of Ischemic stroke in people with migraine: Systematic review and meta-analysis of observational studies. BMJ. 2005; 330: Milhaud D, Bogousslavsky J, van Melle G, Liot P. Ischemic stroke and active migraine. Neurology. 200; 57: Friberg L, Olesen J, Lassen NA, Olsen TS, Karle A. Cerebral oxygen extraction, oxygen consumption, and regional cerebral blood flow during the aura phase of migraine. Stroke. 99; 25: Lipton RB, Stewart WF. Migraine in the United States: a review of epidemiology and health care use. Neurology. 993; 3: S6-0.. Buring JE, Hebert P, Romero J, Kittross A, Cook N, Manson J, et al. Migraine and subsequent risk of stroke in Physicians Health Study. Arch Neurol. 2005; 52: Merikangas KR, Fenton BT, Cheng SH, Stolar MJ, Risch N. Association between migraine and stroke in a large-scale epidemiological study of the United States. Arch Neurol. 997; 5: Chang C, Donaghy M, Poulter N. Migraine and stroke in young women: case-control study. The World Health Organisation Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. BMJ. 999; 38: Tzourio C, Benslamia L, Guillon B, Aïdi S, Bertrand M, Berthet K, et al. Migraine and the risk of cervical artery dissection: A case control study. Neurology. 2002; 59: MacClellan LR, Giles W, Cole J, Wozniak M, Stern B, Mitchell BD, et al. Probable migraine with visual aura and risk of ischemic stroke. Stroke. 2007; 38: Donaghy M, Chang CL, Poulter N; European Collaborators of The World Health Organisation Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Duration, frequency and type of migraine and the risk of ischemic stroke in women of childbearing age. J Neurol Neurosurg Psychiatry. 200; 73: Peatfield RC, Gawel MJ, Rose FC. Asymmetry of the aura and pain in migraine. J Neurol Neurosurg Psychiatry. 98 Sep; (9): Hall GC, Brown MM, Mo J, MacRae KD. Triptans in migraine: The risks of stroke, cardiovascular disease, and death in practice. Neurology. 200; 62(): Zeller JA, Frahm K, Baron R, Stingele R, Deuschl G. Platelet leukocyte interaction and platelet Egypt J Neurol Psychiat Neurosurg. April 200 Vol 7 Issue 2 33

8 activation in migraine: a link to ischemic stroke. J Neurol Neurosurg Psychiatry. 200; 75: Barenbrock M, Spieker C, Witta J, Evers S, Hoeks AP, Rahn KH, et al. Reduced distensibility of the common carotid artery in patients treated with ergotamine. Hypertension. 996; 28: Kurth T, Slomke MA, Kase CS, Cook NR, Lee IM, Gaziano JM, et al. Migraine, headache and the risk of stroke in women: A prospective study. Neurology. 2005; 6(6): Hoekstra-van Dalen RA, Cillessen JP, Kappelle LJ, van Gijn J. Cerebral infarcts associated with migraine: Clinical features, risk factors and followup. J Neurol. 2006; 23: Bousser MG, Welch KM. Relation between migraine and stroke. Lancet Neurol. 2005; : Waters WE, Campbell MJ, Elwood PC. Migraine, headache, and survival in women Br Med J (Clin Res Ed). 983 Nov 2; 287(603): Diener HC, KaubDiener H, Limmroth V. A practical guide to management and prevention of migraine. Drugs. 996; 56(5): 8-2. الملخص العربي دراسة العالقة بين الصذاع النصفى )الشقيقة( والسكتة الذماغية Egypt J Neurol Psychiat Neurosurg. April 200 Vol 7 Issue 2