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Grand Rounds

Antenatal Migraine, Preeclampsia and Risk for Maternal Stroke

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PURPOSE:

  • There is literature to suggest a relationship between migraine headaches and peripartum maternal stroke
  • While this association is likely due to hypertensive disorders of pregnancy, data remains limited
  • Bandoli et al. (JAMA Neurology, 2020) sought to determine if hypertensive disorders in pregnancy is the connection between migraine and maternal stroke

METHODS:

  • Retrospective Cohort Study
    • California birth cohort analyzed (2007 to 2012) | 3 million singleton, live births | Based on linked birth certificates and hospital discharge summaries
  • Migraine, hypertensive disorders of pregnancy, and stroke identified using ICD9 data 
  • Primary outcome
    • Association between migraine and peripartum stroke
  • Statistical analysis
    • Multivariable log-linear regression
    • Adjusted for confounders: Age | BMI | Race and ethnicity | Nativity | Payer source | Mental illness | Smoking | Drug or alcohol use | Diabetes
    • Calculation performed to determine the risk of maternal stroke mediated by gestational hypertensive disorders (mediation analysis)

RESULTS:

  • Patients with migraine: 26,440
  • Patients with strokes: 843 | ischemic strokes comprised 58%

Migraine during pregnancy was associated with increased risk for

  • Hypertensive disorder
    • Migraine: 15.1%
    • No Migraine: 7.0%
    • Adjusted risk ratio (aRR) 1.6 (95% CI, 1.6-1.7)
  • Stroke during pregnancy or delivery
    • Migraine: 0.15%
    • No Migraine: 0.01%
    • aRR 6.8 (95% CI, 4.7-9.8)
  • Postpartum stroke
    • Migraine: 0.05%
    • No migraine: 0.01%; aRR 2.1 (95% CI, 1.2-3.7)
  • Ischemic stroke subgroup
    • Effects were twice as strong in models for ischemic stroke compared with hemorrhagic

Mediation analysis for hypertensive disorders (adjusted)

  • Hypertensive disorders of pregnancy (mostly preeclampsia) mediated a proportion of stroke risk
    • Stroke (pregnancy/delivery): 21%
    • Postpartum stroke: 27%

CONCLUSION:

  • Approximately 25% of strokes in pregnancy that are associated with migraines can be attributed to hypertensive disorders
  • Authors acknowledge some significant limitations
    • Errors regarding accurate timing of the events | Migraines could be falsely coded as a result of a stroke rather than predating the event
    • Likely only severe migraines would be documented and therefore relative risks may not apply to more mild presentations
  • In addition, the authors state that

Although strokes are rare events, the associated morbidity and mortality warrants focus on identifying modifiable intervention targets

Learn More – Primary Sources:

Migraines During Pregnancy and the Risk of Maternal Stroke

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Related ObG Topics:

Is It a Migraine? Risk Factors and Diagnostic Categories
Migraine Treatment and Prevention
ACOG Guidance: Emergency Treatment for Severe Hypertension in Pregnancy

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