Migraine: A Surrogate for More Sinister Pathology?What underlying disorders should primary care clinicians be alert for in patients with migraine?

Since 3000 years BCE, headache sufferers have been writing about their painful history.¹ More specifically, migraines have been a bane to such notable figures as Alexander Pope, Edgar Allan Poe, Frederic Chopin, and Leo Tolstoy. In John Steinbeck's The Wayward Bus, a character, Mr Pritchard, said regarding his wife, " . . . [he] knew her headaches and they were dreadful. They twisted her face and reduced her to a panting, swearing, grinning, quivering blob of pain. They filled a room and a house. They got into everyone around her. Mr Pritchard could feel one of her headaches through walls." This story is similar to one told every day in primary care offices.

LOOKING AT MIGRAINE IN A MORE SERIOUS LIGHT

Recent evidence leads to a question: Have we been too narrow in our focus on migraines, thereby limiting this common, redundant malady to the category of uncomfortable nuisance? Besides pain and immediate disability, can other serious consequences be attributed to this long-chronicled illness? Background information and a recent study cast migraines in a more serious light and implicate their adverse role in a surprisingly extended perspective.

Did you know that migraines are more common in persons with atrial septal defects, pulmonary arteriovenous shunts (as occur in hereditary hemorrhagic telangiectasia), and patent foramen ovale?² In addition, migraines have been associated with an increase in cardiovascular risks. Compared with controls, migraineurs in the Genetic Epidemiology of Migraine (GEM) study were more likely to have elevated low-density lipoprotein cholesterol levels, earlier onset of coronary or CNS vascular disease, and parents with early cardiovascular disease.³ In another large study, migraine with aura in women was associated with an increased risk of myocardial infarction (MI), ischemic stroke, coronary revascularization, and angina.⁴

A recent case-control study included 6102 migraineurs and 5243 persons without migraine.⁵ Migraines both with and without aura were associated with a greater incidence of MI, stroke, and claudication. Migraineurs were more likely than controls to have diabetes (12.6% vs 9.4%; odds ratio [OR], 1.4), hypertension (OR, 1.4), and elevated cholesterol levels (OR, 1.4). Even after adjustment for sex, age, disability, various treatment regimens, and cardiovascular risk factors, migraine persisted as a risk (for example, MI occurred in patients with migraine 2.2 times more often than in controls). In contrast to the GEM study results, all migraines, not only those with aura, were associated with an increased risk of cardiovascular disease.

IMPLICATIONS FOR OFFICE PRACTICE

Currently, these data translate only into heightened attention to identifying and treating cardiovascular risk factors in migraineurs, without specific therapies. The demonstrated risk means strict attention to the primary care list of hypertension, lipid disorders, and diabetes if present.

The evidence has changed my fundamental thinking about migraine, however. Much like erectile dysfunction, which transcends prescription treatment and warrants suspicion of underlying vascular disease,⁶ migraine is more than just a severe headache. Its presence, with or without aura, seems to identify a group of persons prone to a variety of serious cardiovascular events.