Clinical and MRI characteristics in 17 patients with acute migrainous infarction were assessed by researchers at the University of Heidelberg, Mannheim, Germany. Mean age was 44.6 +/- 15.9 years, range 20-71 years, 4 male and 13 female. All had undergone a stroke workup including diffusion-weighted imaging (DWI) between 2 hours and 7 days after onset. DWI lesions affected the posterior circulation in the majority (70.6%), and 29.4% had middle cerebral artery infarction. Multiple lesions were found in 41.2%. MRA was normal in 5 patients; in 4 the artery involving the ischemic territory showed reduced flow. Chronic white matter lesions were demonstrated in 3 cases. Patent foramen ovale was detected in 64.7%. One other risk factor for ischemic stroke was present in 94.1% patients: arterial hypertension in 47.1%, contraceptives 41.2%, nicotine abuse (35.2%), and hyperlipidemia in 35.2%. Coagulation abnormalities occurred in 2 patients. Presentation at the ED varied between 30 min and 5 days after onset of symptoms and deficits, aura symptoms persisting beyond headache relief. Visual aura was the most common symptom (82.3%). Six patients (35.3%) reported residual symptoms from the index event. Differentiation between migrainous infarction and prolonged migraine aura is difficult and associated with delayed admission. [1]

COMMENT. It is controversial whether the migrainous attack is the cause or the symptom of ischemic stroke. By definition (HIS), migrainous infarction is a typical attack of migraine aura in a patient with previous history of migraine with aura and MRI evidence of cerebral ischemia. For cases with concomitant etiology (eg coagulation abnormality), "ischemic stroke coexisting with migraine" is the accepted term. Migrainous infarction is a rare disorder, and prophylactic treatment has not been evaluated. Patent foramen ovale closure may result in decreased frequency of attacks (Morandi E et al, 2003, cited by authors).

Cases meeting the diagnostic criteria for acute migrainous infarction are reported in children. Of 7 children with attacks confirmed by CT, 4 followed for 2 years show no severe residual effect. It is concluded that childhood migraine can be a contributory risk-factor for stroke [2]. Two children with acute confusional migraine and one with migrainous infarction, aged 7-12 years, showed almost complete resolution of symptoms within 24 hrs. Transient occipital slowing on EEG lasted >24 hrs. MRI and MR angiography were normal, but SPECT performed within 48 hrs of migraine attacks revealed a regional change in cerebral blood flow, with hypoperfusion in the posterior cerebral territory. [3]