If a random sample of our population was challenged with describing a typical stroke survivor, what words would be used to construct such an image? I have actually asked this question of those around me in non-medical environments, curious as to what most people consider to be typical. “Paralyzed” is a common perception. “Slurred speech,” “unable to talk,” “can’t walk,” and “can’t move” are others. What I don’t often hear, though, is “refractory pain.” Strokes have been described as clinically silent, with the general perception being that a heart attack is painful, but a brain attack is not.
The reality is – every patient is different, and every stroke is different. Strokes can be painless, or they can be excrutiating, unrelenting, and painful beyond anything imaginable.
Over the coming months, I intend to write a series of posts addressing the issue of chronic pain following stroke – headaches, neck pain, scalp and facial pain, pain affecting arms and legs, thalamic pain syndrome. Pain can be quite prominent aftermath of stroke, especially in the younger stroke population. Often, these patients may have recovered well enough from a physical standpoint to receive numerous comments along the lines of: “You don’t look like you’ve had a stroke.” The response they may desire to give in return is: “You may think that, but I feel like I’ve had a stroke.”
To start the discussion, it is important to understand the relationship that exists between migraine and stroke.
So what is a migraine? This is another question I have posed to random individuals in non-medical settings, and I often ask patients who are experiencing headaches in the clinic what their idea of a migraine is. Often, the explanation involves the notion that a migraine is severe – a headache so intense that the person suffering with it must go to bed in a dark room devoid of sound and light.
Then, I tell them the truth about migraines: “A migraine is not a headache.”
The follow up to this is: “Migraine is an overly excited state in the brain, and a headache is very commonly associated with migraine, but a person can experience frequent migraines and never have a headache.”
Isn’t that interesting? A migraine that does not involve a headache is a strange concept to many. Some people have aura, an associated neurological symptom due to this “overly excited state,” such as seeing flashing lights, zigzag lines, or a smudge in the vision that grows into a large crescent of to engulf all visual fields, a phenomenon known as a scotoma.
Some migraine sufferers experience sensory aura, which involves numbness and/or tingling over the face, arm, and/or leg.
Aphasic aura is an interesting migraine feature that is less common than visual aura or sensory aura, and very much can mimic a stroke at presentation. This involves the inability to speak clearly or potentially impaired understanding of language.
Migraine aura typically (but not always) resolves within an hour without medication, even if the associated headache lasts for hours or days. Other associated migraine symptoms include vertigo, tinnitus (ringing in the ears), nausea, confusion, and even fainting.
Migraine has long been established as a risk factor for stroke, particularly in young patients. The Collaborative Group for the Study of Stroke in Women published in 1975 that patients with migraine carried double the risk of stroke as patients without migraines. More recent data confirmed this risk. A French study found that there was no increased risk of stroke in elderly patients with migraines, while multiple studies have demonstrated an increased risk of stroke in the young migraine sufferer. Having migraine with aura carries an even higher relative risk of stroke than what is seen in patients with migraine who do not experience aura.
Consider this as well (I never miss an opportunity to preach about the dangers of cigarette smoking) – patients with migraine may carry twice the risk of stroke as patients without migraine, but patients with migraine who smoke cigarettes are ten times more likely to experience a stroke. Patients with migraine who smoke cigarettes and who use estrogen-containing birth control pills in one study were 34 times more likely to experience a stroke. I would encourage any migraine sufferer reading this who also uses birth control pills and who smokes to consider laying down the cigarettes and spending that money in other ways.
Why does having migraines increase one’s risk for stroke? Many theories exist, but the jury is still out on exactly why. It may be because the innermost lining of the arteries, called the endothelium, may differ from that which exists in the non-migraine population. It could have something to do with platelets (fragmented blood cells that assist in halting bleeding) functioning differently in migraineurs. Migraineurs are more susceptible to vasoconstriction, or spasming/squeezing in the arteries of the brain. The term for a stroke that occurs in the midst of a migraine episode is migrainous infarction.
Migraines can pose challenges to health care providers attempting to treat them in the young stroke population. Therapy for migraine is best broken down into two arms – abortive therapy, which is used as needed when migraines occur in order to gain relief, and preventative therapy, which is taken daily whether a migraine exists or not in an effort to decrease the frequency and severity of migraine episodes. Please check back for the upcoming post, covering the ground rules of treating migraine in the stroke patient.