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Patients with a history of migraine have an increased risk for ischemic stroke after surgery, leading to more hospital readmissions, according to a study published in the British Medical Journal.1
Migraine affects approximately 20% of the general population and is associated with an increased risk for ischemic stroke.1,2 Among patients who undergo surgery, the perioperative ischemic stroke risk ranges from 0.6 % to 7.4%, with higher stroke rates observed with cardiac and vascular surgery.3,4 The risk for perioperative mortality is 8 times higher after perioperative stroke.3
Matthias Eikermann, MD, PhD, associate professor of anaesthesia at Harvard Medical School and clinical director of the Critical Care Division at Massachusetts General Hospital in Boston, and colleagues examined the relationship between migraine history and risk for perioperative ischemic stroke, as well as 30-day hospital readmission rates in surgical patients, in a prospective registry study.
Of 124,558 surgical patients, 8.2% had migraine; of these, 12.6% had a history of migraine with aura. The incidence of ischemic stroke within 30 days of surgery was 0.6%.
Migraine history was revealed to be a significant predictor of perioperative ischemic stroke (adjusted odds ratio [OR], 1.75), and migraine with aura (adjusted OR, 2.61) was a stronger risk factor than migraine without aura (adjusted OR, 1.62; P <.001).
On the basis of these findings, the predicted absolute risk for perioperative ischemic stroke is 2.4 per 1000 patients overall. Migraine without aura increases this risk to 3.9 per 1000, and migraine with aura increases the risk even further, to 6.3 per 1000.
History of migraine was associated with an increased risk for hospital readmission within 30 days (adjusted OR, 1.31).
An exploratory analysis found that twice as many patients with migraine were readmitted for stroke than patients without migraine (2.0% vs 1.0%; P =.005).1
“Stroke was not the only reason for readmission,” Dr Eikermann told Clinical Pain Advisor. “Patients with migraine were also readmitted for gastrointestinal symptoms and pain.” Migraine is known to be associated with gastrointestinal disease, and readmissions for pain and gastrointestinal symptoms may reflect worsening of migraine after surgery.
Summary and Clinical Applicability
Approximately 1 in 5 people have migraine, which is a known risk factor for ischemic stroke, an important perioperative complication in the surgical population. Researchers found that among patients who underwent surgery, patients with history of migraine had a higher risk for perioperative ischemic stroke and a higher rate of 30-day hospital readmission than patients without migraine.
“The long-term goal is to individualize the anesthetic regimen in order to minimize the risk of stroke in our migraine patients,” Dr Eikermann said. “In an exploratory analysis of our study, we found that using high doses of vasopressors may increase the risk of stroke in migraineurs. Patients with migraine should talk to their anesthesiologist about their migraine history. If they are at high risk of stroke, then maybe we can then create an anesthetic plan that minimizes that risk.”
Limitations and Disclosures
The diagnosis of migraine with aura or without aura was established using International Classification of Diseases, 9th edition, codes, which may be prone to misclassification.
Findings from this exploratory analysis require further investigation
This study was supported by an unrestricted grant from Jeff and Judy Buzen.
References
- Timm FP, Houle TT, Grabitz SD, et al. Migraine and risk of perioperative ischemic stroke and hospital readmission: hospital based registry study. BMJ. 2017;356:i6635. doi: 10.1136/bmj.i6635.
- Smitherman TA, Burch R, Sheikh H, Loder E. The prevalence, impact, and treatment of migraine and severe headaches in the United States: a review of statistics from national surveillance studies. Headache. 2013;53:427-436. doi: 10.1111/head.12074.
- Mashour GA, Shanks AM, Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery. Anesthesiology. 2011;114:1289-1296. doi: 10.1097/ALN.0b013e318216e7f4.
- Bucerius J, Gummert JF, Borger MA, et al. Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. Ann Thorac Surg. 2003;75:472-478.
