Aura and Stroke: relationship and what we have learnt from preclinical models

Abstract

BackgroundPopulation-based studies have highlighted a close relationship between migraine and stroke. Migraine, especially with aura, is a risk factor for both ischemic and hemorrhagic stroke. Interestingly, stroke risk is highest for migraineurs who are young and otherwise healthy.Main bodyPreclinical models have provided us with possible mechanisms to explain the increased vulnerability of migraineurs’ brains towards ischemia and suggest a key role for enhanced cerebral excitability and increased incidence of microembolic events. Spreading depolarization (SD), a slowly propagating wave of neuronal depolarization, is the electrophysiologic event underlying migraine aura and a known headache trigger. Increased SD susceptibility has been demonstrated in migraine animal models, including transgenic mice carrying human mutations for the migraine-associated syndrome CADASIL and familial hemiplegic migraine (type 1 and 2). Upon experimentally induced SD, these mice develop aura-like neurological symptoms, akin to patients with the respective mutations. Migraine mutant mice also exhibit an increased frequency of ischemia-triggered SDs upon experimental stroke, associated with accelerated infarct growth and worse outcomes. The severe stroke phenotype can be explained by SD-related downstream events that exacerbate the metabolic mismatch, including pericyte contraction and neuroglial inflammation. Pharmacological suppression of the genetically enhanced SD susceptibility normalizes the stroke phenotype in familial hemiplegic migraine mutant mice. Recent epidemiologic and imaging studies suggest that these preclinical findings can be extrapolated to migraine patients. Migraine patients are at risk for particularly cardioembolic stroke. At the same time, studies suggest an increased incidence of coagulopathy, atrial fibrillation and patent foramen ovale among migraineurs, providing a possible path for microembolic induction of SD and, in rare instances, stroke in hyperexcitable brains. Indeed, recent imaging studies document an accelerated infarct progression with only little potentially salvageable brain tissue in acute stroke patients with a migraine history, suggesting an increased vulnerability towards cerebral ischemia.ConclusionPreclinical models suggest a key role for enhanced SD susceptibility and microembolization to explain both the occurrence of migraine attacks and the increased stroke risk in migraineurs. Therapeutic targeting of SD and microembolic events, or potential causes thereof, will be promising for treatment of aura and may also prevent ischemic infarction in vulnerable brains.

Exploring the causal inference of migraine on stroke: A Mendelian randomization study

“…Sensitivity analysis showed similar results. These results were also converse to prior evidence of preclinical studies showing the association between migraine with aura and stroke [12], radiological changes such as frequent microinfarct or white matter abnormalities found in migraineurs [13] and reports on sentinel headache preceding stroke events [14].…”

Serum Homocysteine, Pyridoxine, Folate, and Vitamin B12 Levels in Migraine: Systematic Review and Meta‐Analysis

“…The aforementioned association appears to be stronger for MA sufferers compared to MO patients, 17 fuelling the theory that CSD may be a sequel to systematic hypoperfusion disorders 18 . Potential mechanisms that link migraine to vascular diseases include endovascular dysfunction, vasospasm, and additional altered functional vascular properties, 19,20 hypercoagulable states and thrombophilic diathesis, 21,22 as well as the microembolic induction of CSD (increased incidence of atrial fibrillation and patent foramen ovale in migraine patients) 23,24 …”

Assessment of Neurovascular Coupling & Cortical Spreading Depression in Mixed Models of Atherosclerosis & Alzheimer’s Disease

“…There is accumulating evidence to suggest that shared genetic and associated clinical features observed in migraine patients are involved in the increased vulnerability to cerebral ischaemia, therefore, predisposing affected individuals to stroke and white matter lesions associated with dementia (Yemisci & Eikermann-Haerter, 2019). The underlying mechanism being CSD; the neurophysiological feature of aura in migraines, whose induction threshold can be reduced by genetic mutations and systemic comorbidities that contribute to vascular dysfunction and neuroinflammation (Yemisci & Eikermann-Haerter, 2019). Indeed, mouse models of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy syndrome (CADASIL); a genetic cerebrovascular disease caused by NOTCH3 mutations that has a high frequency of migraines with aura, have enhanced CSD linking a dysfunctional neurovascular unit with migraine with aura (Eikermann-Haerter et al, 2011).…”

“…CSD may be the neuropathological link between migraine, stroke, cardiovascular disease and dementia in which cardiovascular risk factors, genetics and other lifestyle factors which prime the onset of migraine to occur lead to vascular vulnerability within the brain predisposing affected individuals to an increased risk of cerebral ischaemia and haemorrhagic stroke (Ripa et al, 2015). There is accumulating evidence to suggest that shared genetic and associated clinical features observed in migraine patients are involved in the increased vulnerability to cerebral ischaemia, therefore, predisposing affected individuals to stroke and white matter lesions associated with dementia (Yemisci & Eikermann-Haerter, 2019). The underlying mechanism being CSD; the neurophysiological feature of aura in migraines, whose induction threshold can be reduced by genetic mutations and systemic comorbidities that contribute to vascular dysfunction and neuroinflammation (Yemisci & Eikermann-Haerter, 2019).…”

“…There is accumulating evidence to suggest that shared genetic and associated clinical features observed in migraine patients are involved in the increased vulnerability to cerebral ischaemia, therefore, predisposing affected individuals to stroke and white matter lesions associated with dementia (Yemisci & Eikermann-Haerter, 2019). The underlying mechanism being CSD; the neurophysiological feature of aura in migraines, whose induction threshold can be reduced by genetic mutations and systemic comorbidities that contribute to vascular dysfunction and neuroinflammation (Yemisci & Eikermann-Haerter, 2019).…”