Primary Care Corner with Geoffrey Modest MD: Migraine and Heart Disease in Women

By Dr. Geoffrey Modest

Analysis of the Nurses’ Health Study found a significant increase in cardiovascular disease in those with migraine

(see http://dx.doi.org/10.1136/bmj.i2610 ).

Details:

  • 115 541 women aged 25-42 years at baseline and free of angina and cardiovascular disease were followed from the prospective Nurses’ Health Study II (from 1989-2011)
  • Mean age 35; BMI <25 in 68%, 25-30 in 19%; history hypertension 6%, hypercholesterolemia 12%, smoking 14%; no alcohol in 38%, up to 15 g/d in 58%; oral contraceptives in 12%.
  • 17 531 (15.2%) women reported a physician’s diagnosis of migraine (though no data on presence of aura, migraine frequency, or migraine meds)
  • Women with migraine were more likely to have hypertension, hypercholesterolemia, family history of MI, BMI>30 or be current smoker

Results:

  • 1329 major cardiovascular disease events occurred, and 223 women died from cardiovascular disease
  • Adjusting for potential confounding factors (age, cholesterol, diabetes, hypertension, BMI, smoking, alcohol, physical activity, postmenopausal estrogens, menopausal status, oral contraceptives, aspirin/acetaminophen/NSAID use, and family history MI), migraine was associated with an increased risk for:
    • Major cardiovascular disease (hazard ratio1.50, 95% confidence interval 1.33 to 1.69)
    • Myocardial infarction (HR 1.39, 1.18 to 1.64)
    • Stroke (HR 1.62, 1.37 to 1.92)
    • Angina/coronary revascularization procedures (HR 1.73, 1.29 to 2.32)
    • Cardiovascular disease mortality (HR 1.37, 1.02 to 1.83)
    • Associations were similar across subgroups of women, including by age (<50/≥50), smoking status (current/past/never), hypertension (yes/no), postmenopausal hormone therapy (current/not current), and oral contraceptive use (current/not current)

Commentary:

  • Several studies have found that migraine (specifically migraine with aura) is associated with increased risk of stroke
  • The Women’s Health Initiative found similar increase in cardiovascular disease (about the same +/- 50% increase as above), but only in those reporting migraine with aura
  • Several other studies from different countries (Taiwan, Iceland, as well as the American Migraine Prevalence and Prevention Study) have found similar results
  • How to explain the association?? Unclear. ?increased thrombogenic susceptibility, shared genetic markers, endothelial dysfunction, or inflammation (all have been shown in both migraine and cardiovascular disease). And a recent small study found that the combination of a statin and vitamin D, perhaps through their anti-inflammatory or endothelial effects, decreased the frequency of migraines (for analysis of this study, see prior blog: http://blogs.bmj.com/bmjebmspotlight/2016/01/06/primary-care-corner-with-geoffrey-modest-md-migraine-prophylaxis-with-simvastatinvitamin-d
  • So, it probably makes sense to include migraine (perhaps more so if aura present) in the overall gestalt of cardiovascular risk factors – e., it would be an added reason to strongly encourage lifestyle changes (smoking, appropriate weight, increasing fruits/veges in diet, exercise) in general, and it might sway me to use statins in those otherwise on the borderline for medical therapy

 

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