It's not all in your head
Migraines linked to higher risk stroke and heart attack
Monique Johannet remembers riding a bike as a child and seeing the light change.
"Suddenly, there'd be cool, wiggly light things going on in my range of vision," the 55-year-old Watertown artist said.
Although the auras started early, the slamming pain of the migraine didn't come with the "cool, wiggly things" until her late 30s. Now she keeps a diary to keep track of the new moons, cold fronts, and emergency room visits, all connected to the hand with the long, steel nails that slides into her head and squeezes.
About 28 million people suffer from migraines, including 18 percent of women and about 6.5 percent of men. Although the pain often knocked victims out for hours or even days, migraines used to be seen as merely a quality of life issue - they were painful, they caused problems, but it was just a headache.
But new studies have shown increasing links between people who have migraines and a higher risk of stroke and heart attack. In some cases, the risk is double compared to those who don't have migraines.
Doctors aren't sure why there's a link, but say the new research is a heads up to both patients and physicians that migraines should be seen as more than just recurrent pain, but as a potential warning of something more serious.
"I tell my patients that there is an urgency in controlling their headaches and I don't want them having more than a couple of attacks a month," said Dr. Zahid Bajwa, director of education and clinical pain research at Harvard Medical School.
"Anybody who has four to six attacks a month, and they last more than a couple hours - I worry about those patients."
The risks aren't slight. A 2005 analysis of 14 studies in the British Medical Journal found that people with migraines had 2.16 times the risk of stroke. Those who took birth control pills were eight times as likely to have a stroke, which doctors attribute to an abrupt estrogen withdrawal - a common migraine trigger - when women cycle off the pill for five days.
Another 2007 study, in the journal Stroke, looked just at women with migraines and found that those who had an aura were up to seven times more likely to suffer a stroke than women who had never had a migraine.
About 15 percent of those who get migraines get an aura - changes in vision or super-sensitivity to sound or smell - about an hour before the headache occurs. But not everyone who gets an aura has the headache. And it's unclear why those who have auras have more strokes.
"The bottom line is that migraines with aura produce complications," said Dr. Richard B. Lipton, director of the Montefiore Headache Center and vice chair of Neurology at the Albert Einstein School of Medicine in New York. "It's a risk factor for heart attacks and stroke in the same way as high blood pressure, diabetes, and high cholesterol."
Doctors believe the aura is caused by changes in the nerve cells in the brain, which activate neurons in the membranes surrounding the brain and directly cause the pain.
One new theory in the link between auras and strokes and heart attacks came from a study in the April edition of the journal Neurology. It found that those with migraines with aura had lower counts of endothelial progenitor cells, which line the blood vessel walls and help the blood flow smoothly.
The theory is that the frequent expansion and contraction of the blood vessels during a migraine weakens the vessel walls and makes them more prone to the build-up of plaque, which causes blood clots. Those blood clots can then lead to heart attacks and strokes.
Patients with heart disease and stroke have also been found to have lower counts of EPC cells. Those with low counts could mean that the blood vessels have a hard time repairing themselves when damaged.
While doctors know there's a link, they're unsure what to do about it.
"You put a physician in front of a patient with multiple risk factors - cigarette smoking, high cholesterol, and migraines with aura - and you add them all up, and the best we can do right now is simple, cheap, and effective daily prevention," to lower some of the high risk factors for stroke and heart attack, said Herbert Markley, director of the New England Regional Headache Center Inc. in Worcester.
That means, exercise, diet, and possibly drug therapy for high cholesterol and blood pressure, he said.
Johannet, the artist from Watertown, said she's very careful about watching her cholesterol and other risk factors. She said her goal is to lower the number of migraines she has naturally by watching her diet, doing yoga, and avoiding triggers such as wine.
She says she stopped taking migraine medication because of the side effects, but she regularly discusses her migraines with her primary care doctor.
"I think he really kind of respects my effort to work with this and overcome it," Johannet said.
Headache specialists believe that lowering the frequency of the migraine attacks will lower the risks of stroke and heart attack. But that theory is still under study.
"Whatever puts migraines into remission is good for them, whether it's physical therapy, biofeedback, or medication," such as antiseizure drugs, said Bajwa, the Harvard doctor. "What is bad for them is becoming dependent on the 'as needed' medication, like Tylenol 3 or Vicodin, which they take just so they continue to function."
Part of the problem is that many patients don't take their migraines seriously.
Kaitlin Wolfberg, 21, the creator of a MySpace migraine support group, said she's organized her life around her migraines, giving up a loud, intense job at a bar for the quiet solitude of a florist shop.
"I've been on migraine medication my whole life and it just didn't work for me," she said. "It affected my creativity and my personality and I lost a lot of weight. It was terrible. But it did stop the cycle of migraines."
Now that she's given up the medication, she has headaches almost every day. Although she rarely has the aura, she says she's hesitant to talk to doctors about her headaches - even if they could cause long-term problems.
"After a while, if you don't start feeling better, doctors just get annoyed and frustrated and give up on you," she said. " I just live with the headaches." 