In an accompanying editorial, Dr. Elizabeth Loder, of the Department of Neurology, Brigham and Women's/Faulkner Hospitals and Harvard Medical School, added valuable perspective. She wrote:²

"Schürks and colleagues did not find a significant association between migraine and myocardial infarction or death from cardiovascular disease. Their findings should be interpreted cautiously, however, because the number of studies was too small to examine risks in subgroup. It is possible that when additional studies are available they will show that the size of the association between migraine and cardiac outcomes is different in people with and without aura."

"The clinical implications of these findings are that patients who have migraine with aura should be followed closely and treated aggressively for modifiable cardiovascular risk factors. Counselling patients about their increased risk of stroke may increase adherence to recommended treatment, but the information should be put in context-the absolute risk of stroke for most patients with migraine is low, so a doubling of risk is not cause for panic. At a population level, however, this risk deserves attention because the prevalence of migraine is so high."

"All of this suggests that clinicians need to identify young women with migraine, particularly those who are seeking oestrogen containing hormonal contraception. Those who have migraine without aura and are otherwise appropriate candidates for hormonal contraception should not be denied its benefits, because we have no convincing evidence of a clinically meaningful increased risk of stroke. For women who have aura, however, decisions about the use of hormonal contraception are more difficult."

Summary and comments

At the beginning of this article, I asked that you read to the end for perspective. To help with that, I go back to an interview with Dr. Fred Sheftell, Founder and Director of the New England Center for Headache.