Migraine and Cardiovascular Disease: What's the Link and Who's Most at Risk?

As if more evidence is needed to confirm that migraine is not “just a headache,” multiple studies over the years have shown that migraine is linked to an increased risk of cardiovascular disease (CVD), especially stroke. This risk is especially greater among women, and in people who have migraine with aura.

A 2022 cross-sectional study published in the journal Frontiers in Cardiovascular Medicine confirmed a clear association between migraine and CVD, and concluded that migraine should be considered an important risk factor for CVD.

“There is an interesting relationship between migraine and stroke,” says Andrew Charles, MD, professor of neurology and director of the UCLA Goldberg Migraine Program. “There is an increased risk of stroke in those with migraine — particularly in migraine with aura and particularly in those who have aura with the majority of their attacks. Those are individuals for whom healthcare providers have a concern about the risk of stroke. It's not a high risk, but it is a risk factor.”

Dr. Charles says that some people erroneously believe that strokes occur during migraine attacks. “In fact, it is exceedingly rare for strokes to occur as a result of a migraine attack, where the migraine itself is the cause of stroke.”

What Is the Link Between Migraine and Cardiovascular Disease?

Researchers aren't sure exactly what links migraine and heart disease, but there are a few theories, one of which has to do with blood vessels:

“The link is certainly not clear, but we surmise that it has to do with the fact that the blood vessels are involved in both conditions, including migraine and stroke,” says Huma Sheikh, MD, a neurologist specializing in migraine and stroke at NY Neurology Medicine in New York. “In different cardiovascular diseases, especially stroke, there is either a change in the caliber of the blood vessel or a clot that forms. The studies show that this link still occurs even when other conditions like diabetes and hypertension are taken out of consideration,” she says.

Still, the exact blood vessel issue has not yet been pinned down. Another theory is that a narrowing of the arteries, which is an old-school hypothesis on the cause of migraine, might be the common link between migraine and heart disease. (The newer thinking on the pathophysiology of migraine is much more complex.)

One 2021 study looked at 252 women with angina, or chest pain caused by reduced blood flow to the heart not caused by a blood vessel blockage. Half of the women also had migraine, and reported more angina at rest, with strong emotions, and with temperature extremes. 

However, the study concluded that this angina may not be related to having migraine nor did it increase their risk for having a cardiovascular event. More studies are needed to better understand the association between migraine and CVD.

Other theories include:

• Irregular heartbeat (as in atrial fibrillation)
• General cardiovascular risk factors like unfavorable cholesterol numbers and high blood pressure, which have been shown to be more prevalent in people with migraine
• The presence of a patent foramen ovale (PFO), or hole in the heart, in some people
• The overuse of nonsteroidal anti-inflammatory drugs (NSAIDs)

Genetics May Not Be a Factor

One thing experts are pretty sure does not explain the link is genetics. This is somewhat surprising, considering that both heart disease and migraine have strong genetic components. 

A large study published in 2015 in the journal Neurology Genetics looked at 159,000 people, including 20,000 people with migraine and 21,000 people with heart disease.

"Surprisingly, when we looked for shared gene variants that might help explain part of the link between migraine and heart disease, we found no shared gene variations between migraine with aura and heart disease," said study author Aarno Palotie, MD, of the Broad Institute of MIT and Harvard.

"This is surprising because the evidence is stronger that people with migraine with aura have an increased risk of heart disease than people with migraine without aura," he said.

Migraine With Visual Aura

Visual aura during a migraine attack usually occurs before the acute head pain begins. The American Migraine Foundation (AMF) estimates that about 25 to 30 percent of people with migraine experience aura. 

Examples of visual aura include sparkles or zigzag lights in the vision that may move, flash, or get larger.

In the 2015 study, researchers used four methods to analyze the data for shared genetic variants that overlap between migraine and heart disease. Even though evidence suggests that people with migraine with visual aura have a greater risk for heart disease and ischemic stroke (when the blood supply to the brain is interrupted or reduced) than those with migraine without aura, researchers found no common gene variations between migraine with aura and heart disease.

However, they did find common genetic variations in migraine without aura and heart disease. Surprisingly, those shared genes actually protect against heart disease rather than increase the risk.

"In other words, people with migraine without aura seem to have a lower load of genetic factors increasing the risk of heart disease," said Anne Ducros, MD, PhD, of the University of Montpellier in France, in an editorial she wrote accompanying the study.

"We now need to understand why people with migraine who are born with a protective or neutral genetic risk for heart disease end up with an increased risk for heart problems," she said.

Dr. Ducros added that genetic factors not included in these studies could still affect the risk of heart disease among those with migraine. She also suggested that nongenetic factors like obesity, lack of exercise, smoking, and depression that all increase the risk of heart disease may be involved in the migraine and heart disease link.

Migraine With Aura and Irregular Heartbeat

People who experience migraine with visual aura may have an increased risk of an irregular heartbeat called atrial fibrillation, according to a 2018 study published in Neurology, the medical journal of the American Academy of Neurology.

Atrial fibrillation is a form of arrhythmia. meaning the heart's normal rhythm is out of sync. This could lead to blood pooling in the heart, possibly forming clots that make their way to the brain, causing a stroke. 

The study looked at nearly 12,000 people of an average age of 60, who were followed for up to 20 years. After adjusting for age, sex, blood pressure, smoking, and other factors that could affect risk of atrial fibrillation, people with migraine with aura were found to be 30 percent more likely to develop the condition than people who did not have headaches and 40 percent more likely to develop it than people with migraine without aura.

Since atrial fibrillation is a risk factor for strokes caused by blood clots, this demonstrates another clear link between migraine with aura and stroke. As far as the risk of stroke, researchers found the incidence to be as follows:

• 4 out of 1,000 annually in people with migraine with aura
• 2 out of 1,000 annually in people with migraine without aura
• 3 out of 1,000 annually in those without headache

Cardiovascular Risk Factors

Multiple studies over the years have found that migraine patients have higher rates of hypertension and high cholesterol compared to people without migraine. A small Dutch study in 2005 also found higher rates of smoking and early familial heart attack events in people with migraine, compared to those without. However, many studies have shown that even after adjusting for these traditional vascular risk factors, the association remains.

In a 2013 study, migraine was also associated with metabolic syndrome, a cluster of conditions that increase the risk of heart disease, stroke, and type 2 diabetes.

And another study in 2009 showed that two female-specific risk factors for CVD — gestational hypertension and preeclampsia — occur more often in women with migraine than in women without.

A Hole in the Heart and Migraine?

Another possible underlying cause of migraine that has been identified is the presence of a congenital heart defect known as a patent foramen ovale (PFO). In the simplest of terms, this is basically a hole between the upper chambers of the heart. This hole is present in everyone before birth and is supposed to close shortly after birth. When it doesn’t, most people can go through life not knowing it; however, it can increase your risk for developing migraine, among other complications.

Experts aren’t sure what links migraine to a PFO, but research suggests it might be related to the blood platelets. 

Tiny blood clots too small to cause a stroke may reach the brain, triggering migraine attacks, or chemicals released by the platelets may be responsible, according to Robert J. Sommer, MD, a cardiologist at New York-Presbyterian. “As many as 40 to 50 percent of individuals who experience migraines with aura also have a PFO,” he says. “That’s twice the rate of patients without migraine or with migraine without aura.”

PFOs can be closed with a catheter or surgery, which can result in a dramatic reduction of migraine frequency in some patients but also make minimal difference for others.

One permanently implanted device is currently in clinical trials as of October 2023 to assess whether it can provide relief for patients with migraine.

The Treatment Dilemma

Because of the association between migraine and CVD, an individual’s risk factors need to be taken into account before prescribing certain migraine medications, including triptans. Because triptans constrict the blood vessels, they are contraindicated in patients with uncontrolled hypertension, coronary artery disease, and in patients who have had a stroke or transient ischemic attack (TIA). 

However, this does not necessarily mean triptans need to be avoided at all costs. “Many observational studies over years have not shown any direct link between stroke or heart attack being caused by a triptan,” says Dr. Sheikh. “As long as these conditions are under good control, triptans are a viable option. In patients in which these are not well controlled, or who have had an MI [myocardial infarction, the technical term for heart attack] or stroke, most physicians are more cautious to give triptans and would likely avoid them,” she says.

In people with both migraine and hypertension, beta-blockers can multitask as both a migraine preventive and a blood pressure–lowering drug. Other preventives that are not restricted for patients with CAD include topiramate (Topamax), valproic acid, and onabotulinumtoxinA (Botox).

In a study overview published in Headache in 2020, researchers concluded that although “the risk of acute coronary syndromes in the treatment of migraine attacks with triptans appears to be extremely low,” triptans are still contraindicated in patients with known angina pectoris (chest pain) and history of heart attack. Instead, experts suggested these patients treat their migraine attacks with over-the-counter (OTC) remedies like aspirin, acetaminophen, or NSAIDs.

However, as mentioned earlier, NSAIDs might not be the best either if you have chronic or high-frequency attacks, as chronic use or overuse of them have been associated with an increased risk of atrial fibrillation or a heart flutter. 

One study published in The BMJ in 2011 showed a 40 to 70 percent increase in the risk of developing this condition with chronic use of NSAIDs. And another study published in the journal Rheumatology in 2014 showed an increased risk of developing blood clots in the deep veins, which can lead to stroke.

What Migraine Medications Are Safe if You Have Cardiovascular Disease?

So what is safe to take for migraine if you do have these risk factors? The newer acute and preventive medications for migraine — calcitonin gene-related peptide (CGRP) antagonists, the small-molecule gepants, and lasmiditan (Reyvow) — appear to be suitable for patients at risk of coronary artery disease, as they do not affect the blood vessels. 

Another migraine medication that was recently found safe (contrary to previous contraindication) for people with significant cardiovascular risk is dihydroergotamine (DHE), often administered in the emergency department as part of the migraine cocktail. 

Data from a single-center, retrospective cohort study published in Headache in late 2023 reported no significant cardiovascular events or electrocardiogram (EKG) abnormalities among patients with elevated risk factors for CVD who had received intravenous DHE to abort a migraine attack. The study also showed repetitive use was safe in patients with refractory chronic migraine.

How Concerning Is the Link Between Migraine and Heart Disease?

"Fortunately, the absolute risk of migraine-related stroke is low," says headache specialist Gretchen E. Tietjen, MD, professor emerita of neurology at the University of Toledo. In her talk for the 2023 Migraine World Summit, she said “the percentage of strokes that are associated with migraine is small. So it’s not super common to have a stroke associated with migraine.” 

A 2020 study published in JAMA followed nearly 28,000 women who were part of the Women’s Health Study that began in the early 1990s. All were ages 45 and older with no evidence of CVD when the study began. Researchers tracked the women’s health until 2018. 

Just 5 percent of the women in the study reported having migraine with aura. Their annual rate of heart attack, stroke, or death from CVD was slightly higher (3.4 per 1,000 women) than the rate among women who had migraine without aura or no migraine at all (2.1 per 1,000 women).

“If someone has aura, it is important to speak with your physician about how to minimize the risk, including making sure all other risk factors are also well under control, especially if one smokes,” Sheikh says. “It’s important to also try to treat the migraine with aura and have it under control, with the least amount of frequency and severity of the auras.”

Women who are 35 or older who have migraine with aura should consult with their primary care physician or gynecologist about nonhormonal or estrogen-free birth control, as estrogen therapy may further raise the risk of stroke in some women. “Estrogen-containing contraceptives are also controversial in this instance and therefore it needs to be addressed with a physician if someone with migraine is taking them,” says Sheikh. “The studies are controversial.”

It’s important to note that any new symptoms that are different from your typical aura symptoms, such as numbness or weakness in your hands or arms, should not be dismissed as migraine. Seek emergency care if you experience any such new symptoms.

How to Lower Your Risk of Heart Disease

There are several proactive steps you can take to reduce your risk of heart disease. These tips from Dr. Tietjen and the American Migraine Foundation do double duty, as they also can help reduce your migraine frequency:

• Eat a healthy diet and drink plenty of water.
• Get regular exercise. If exercise aggravates your migraine attacks, ease into a gradual exercise plan or try one of these gentle fitness goals.
• Commit to eight hours of sleep each night.
• Ask your doctor to evaluate you for conditions known to cause stroke and heart diseases, like high blood pressure, high cholesterol, and diabetes. Work with your doctor to treat these conditions if you are diagnosed with any of them.
• If you smoke, quit.
• Ask your doctor whether meds that decrease inflammation, decrease clotting (such as daily aspirin), or repair the endothelium (such as a statin with vitamin D) are right for you, in addition to the traditional migraine preventives.
• Avoid the use of estrogen-containing contraceptives, especially if you smoke or have a personal or family history of blood clots. Progestin-only contraception, which has recently become available OTC, has less risk.
• Avoid chiropractic manipulation of your neck.
• Consult your doctor or headache specialist before using triptans if you have a history of heart disease or stroke, or if you have attacks with weakness on one side (possible hemiplegic migraine), or vertigo, and gait imbalance that could indicate possible basilar migraine.

Final Thoughts

Research links migraine with an increased risk of heart disease and stroke, especially migraine with visual aura. Luckily, the overall risk is still low. Lifestyle changes that improve your heart health also can prevent migraine. Even better, strategies that lower the heart rate and reduce stress — like mindfulness, relaxation strategies, or other behavioral therapies — can also benefit both your head and your heart.

Do you live with both migraine and cardiovascular risk factors? Please share any tips on how you manage both conditions with the community at Tippi!

Angie Glaser contributed to this article.