Stroke and Headache Headache and Stroke

Transcription

1 Stroke and Headache Headache and Stroke Hans-Christoph Diener Senior Professor of Clinical Neurosciences University Duisburg-Essen Tobias Kurth Institute of Public Health Charité Universitätsmedizin Berlin Germany

2 Conflict of Interest Statement (Headache) German Research Council German Ministry of Education and Reserach EU Addex Alder Allergan Almirall Amgen Astra-Zeneca Bayer BMS Böhringer-Ingelheim Chordate Coherex CoLucid Eisai Electrocore Endo Pharmac. GSK Janssen-Cilag J&J Labrys Lilly MAP Menarini Medtronic MSD Neuroscore Novartis Novo Nordisk Pfizer Sanofi-Aventis Schering Solvay St. Jude Medical Teva Weber & Weber Wyeth

3 Conflict of Interest Statement (Stroke) The speaker or his institution received financial support from the following bodies or companies: German Research Council German Ministry of Health German Ministry of Science and Technology European Union Bertelsmann Foundation Heinz-Nixdorf Foundation Abbott Allergan Achelios Actelion AstraZeneca Bayer Boehringer Ingelheim Brainsgate BristolMyersSquibb CoAxia Corimmun Covidien D-Pharm Daiichi-Sankyo Fresenius GlaxoSmithKline Jansen-Cilag Johnson&Johnson Lilly Lundbeck Medtroni Mindframe MSD Neurobiological Technologies Novo Nordisk Novartis Paion Pfizer Sanofi Schering Schering Plough Servier Solvay St. Jude Syngis Tacrelis Thrombogenics

4 Overview Headache in stroke Pathophysiology of headache in stroke Epidemiology of stroke and migraine Migraine and structural brain lesions Migraine and arterial dissection Migraine and PFO SMART Posterior reversible encephalopathy syndrome Stroke mimics Here is the summary and conclusion 4

5 Overview Headache in stroke Pathophysiology of headache in stroke Epidemiology of stroke and migraine Migraine and structural brain lesions Migraine and arterial dissection Migraine and PFO SMART Posterior reversible encephalopathy syndrome Stroke mimcs 5

6 Headache in Stroke 6

7 Headache in Stroke 7

8 Headache associated with ischemic stroke Presentation and course Onset abrupt or gradual More frequent in posterior circulation strokes More severe in basilar artery stroke Sentinel headache only in SAH Late onset associated with brain edema 8

9 Overview Headache in stroke Pathophysiology of headache in stroke Epidemiology of stroke and migraine Migraine and structural brain lesions Migraine and arterial dissection Migraine and PFO SMART Posterior reversible encephalopathy syndrome Stroke mimcs 9

10 Schlaganfall und Kopfschmerzen Lesions were summed 10

11 Schlaganfall und Kopfschmerzen Involvement of the central pain network 11

12 Overview Headache in stroke Pathophysiology of headache in stroke Epidemiology of stroke and migraine Migraine and structural brain lesions Migraine and arterial dissection Migraine and PFO SMART Posterior reversible encephalopathy syndrome Stroke mimcs 12

13 Epidemiologic evidence: migraine-stroke First description of migrainous infarct likely by Charcot and Féré ~1883 Several clinic- and population-based studies found an association between migraine and increased risk of ischemic stroke Consistent findings from cross-sectional, casecontrol, and cohort studies Particular increased risk for younger women (<45 years) Most studies found increased risk of stroke only among migraineurs with aura

14 Epidemiologic evidence: migraine-stroke, cont. Findings from prospective cohort studies: Atherosclerosis Risk in Communities Study (ARIC) included 12,409 men and women mostly aged >55* Migraine/headache assessed via interview Medical record validated strokes Women s Health Study (WHS) included 39,754 women aged >45 and free of cardiovascular disease ** Migraine/headache self-reported Medical record confirmed stroke * Stang et al. Neurology 2005; 64: ** Kurth et al. Neurology 2005; 64:1020-6

15 Relative Risk Epidemiologic evidence: migraine-stroke, cont. Association between migraine/headache and ischemic stroke 2,5 2,0 1,5 1,0 Migraine + aura Migraine - aura Non-migraine headache 0,5 0,0 ARIC* WHS** Risk of stroke increased in migraine with aura * Stang et al. Neurology 2005; 64: ** Kurth et al. Neurology 2005; 64:1020-6

16 Migraine and stroke: meta-analysis Case-control and cohort studies included 9 studies evaluated association between migraine and ischemic stroke from different source populations If studies uses same underlying source population, only longest follow-up or cohort design was selected Overall migraine associated with 70% increased risk of ischemic stroke (RR=1.73; 95% CI= ) Association only apparent among migraineurs with aura Schürks et al. BMJ 2009;339:b3914

17 Migraine and stroke: meta-analysis, cont. Association between migraine with and without aura and ischemic stroke Risk of stroke increased in migraine with aura Schürks et al. BMJ 2009;339:b3914

18 Relative Risk Migraine and stroke: meta-analysis subgroups Relative Risk of Ischemic Stroke Overall MA MO Women <45 + OC + Smoking Most important risk factors: oral contraception and smoking Schürks et al. BMJ 2009;339:b3914

19 Migraine and hemorrhagic stroke Migraine with aura increased the risk of hemorrhagic stroke RR = 2.31 ( ) Kurth et a. BMJ 2010;c3659

20 Relatives Risko Migraine and hemorrhagic stroke Adjusted Relative Risk 4,0 3,5 3,0 2,5 2,0 1,5 1,0 0,5 0,0 Hem. Stroke ICH SAH Fatal MA Migraine increases the risk of intracranial hemorrhage Kurth et a. BMJ 2010;c3659

21 Epidemiology Migraine is a risk factor for any vascular disease 21

22 Migraine and perioperative stroke Risk of stroke within 30 days of surgery (N= ) 22

23 Migraine and perioperative stroke Risk of perioperative ischemic stroke increased by 75% 23

24 CT and CT angiography 24

25 No increased risk of atherosclerosis in patients with migraine and stroke 25

26 Summary Migraine with aura is a risk factor for ischemic stroke Migraine is a risk factor for cerebral hemorrhage Migraine with aura is a risk factor for vascular diseases Migraine increases the risk of perioperative stroke Patients with migraine have more vascular risk factors (but not more atherosclerosis) Patients with migraine might have dysfunction of the endothelium 26

27 Migraine genetics 27

28 Migraine genetics The new gene loci code for vascular endothelium, CNS pain structures, GI tissue and smooth muscle 28

29 Overview Headache in stroke Pathophysiology of headache in stroke Epidemiology of stroke and migraine Migraine and structural brain lesions Migraine and arterial dissection Migraine and PFO SMART Posterior reversible encephalopathy syndrome Stroke mimcs 29

30 Migraine and structural brain lesions Several studies have linked migraine with increased load of white matter lesions and increase in infarctlike lesions in the posterior circulation The CAMERA study showed: Migraine associated with 7-fold increase in risk of infarctlike lesions in cerebellum with migraine frequency and among migraine with aura In women, migraine with aura doubled risk of deep WML No difference according to migraine aura status Reykjavik study showed: Migraine with aura in midlife increased infarct-like lesions the cerebellum in late-life by 60% Result only apparent among women (RR = 1.9)

31 % with High-DWML-load Deep WML in migraine patients The Dutch CAMERA general population MRI study 35,0 30,0 25,0 20,0 15,0 10,0 5,0 0, Quintiles of attack frequency Migraineurs (n=195) Controls (n=140) Effect attacka frequency in women < 50 yr 1 Controls 4,6 p<0.03 Migraine <1/month 7,8 p<0.005 Migraine >1/month Kruit MC, et al. JAMA 2004; 291:

32 Migraine, white matter lesions and silent brain infarcts 32

33 Migraine, white matter lesions and silent brain infarcts No increase in white matter lesions and silent brain infarcts in migraine with aura 33

34 Overview Headache in stroke Pathophysiology of headache in stroke Epidemiology of stroke and migraine Migraine and structural brain lesions Migraine and arterial dissection Migraine and PFO SMART Posterior reversible encephalopathy syndrome Stroke mimcs 34

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37 Overview Headache in stroke Pathophysiology of headache in stroke Epidemiology of stroke and migraine Migraine and structural brain lesions Migraine and arterial dissection Migraine and PFO SMART Posterior reversible encephalopathy syndrome Stroke mimcs 37

38 Migraine with aure and patent foramen ovale (PFO) PFO occlusion not effective to prevent migraine with aura 38

39 Summary Conflicting data concerning white matter lesions and silent brain infarcts in migraine with aura Migraine is a risk factor for dissection PFO closure does not prevent migraine with aura 39

40 Overview Headache in stroke Pathophysiology of headache in stroke Epidemiology of stroke and migraine Migraine and structural brain lesions Migraine and arterial dissection Migraine and PFO SMART Posterior reversible encephalopathy syndrome Stroke mimcs 40

41 a Headache in combination with prolonged reversible neurological signs 41

42 Overview Headache in stroke Pathophysiology of headache in stroke Epidemiology of stroke and migraine Migraine and structural brain lesions Migraine and arterial dissection Migraine and PFO SMART Posterior reversible encephalopathy syndrome Stroke mimcs 42

43 a Headache frequent symptom 43

44 a Triggers or associations with PRES Autoimmune disorders Systemic LE TTP Scleroderma Crohn s disease Rheumatoid arthritis Immunosuppressive or cytotoxic drugs Ciclosporine Tacrolimus Antiangiogenic drugs Triggers or associations with PRES Renal failure Hypertensive crisis Low magnesium Pregnancy Headache frequent symptom 44

45 Overview Headache in stroke Pathophysiology of headache in stroke Epidemiology of stroke and migraine Migraine and structural brain lesions Migraine and arterial dissection Migraine and PFO SMART Posterior reversible encephalopathy syndrome Stroke mimics 45

46 a 46

47 Overview Headache in stroke Pathophysiology of headache in stroke Epidemiology of stroke and migraine Migraine and structural brain lesions Migraine and arterial dissection Migraine and PFO SMART Posterior reversible encephalopathy syndrome Stroke mimics 47

48 Thank you