Migraine is often dismissed as “just a headache”, but scientific research paints a far more complex picture. This neurological condition may have far-reaching consequences for brain health that extend well beyond the painful attacks.
Silent damage in the brain
A groundbreaking study (Kruit et al., 2004) found that people with migraine, especially women with aura, more often have small, silent brain infarcts. These tiny infarcts are often just a few millimetres in size and are found mainly in the cerebellum and the deep white matter. The study suggests that migraine is more than a headache: it can cause subtle but significant damage in the brain.
This finding was revolutionary because, for the first time, it established a direct link between migraine and structural changes in the brain. Follow-up research has confirmed and extended these results, showing that people with migraine not only have more white matter lesions, but also run a higher risk of other vascular problems.
The mechanism behind the damage
These “silent” lesions probably arise from temporarily reduced blood flow (hypoperfusion) or micro-emboli (small blood clots) that block a vessel. Although they often cause no immediate symptoms, in the long term they can increase the risk of stroke and cognitive problems.
The brain is extremely sensitive to changes in blood supply. Even short periods of reduced oxygen supply can cause permanent damage to delicate neuronal networks. In migraine, these episodes seem to happen repeatedly, which gradually leads to an accumulation of microscopic damage.
An intriguing hypothesis: clots as a trigger
These findings fit with an intriguing hypothesis: could subclinical blood clots not only cause damage, but also trigger migraine attacks themselves? Micro-clots can temporarily restrict blood flow to specific areas of the brain, leaving neurons short of oxygen and glucose. This may set off cortical spreading depression (CSD), a wave of neuronal hyperactivity followed by suppression, which is linked to migraine aura.
Risk factors and individual differences
Not everyone with migraine has the same risk of brain lesions. Women who have migraine with aura appear to be the most vulnerable, possibly because of hormonal factors that affect blood clotting. The frequency and intensity of attacks also play a role: people with frequent, severe migraine are more likely to have structural brain changes.
Other risk factors that increase the chance of vascular complications in migraine are:
- Smoking
- Use of hormonal contraception
- High blood pressure
- Diabetes
- Abnormal cholesterol levels
- A family history of cardiovascular disease
Long-term consequences: cognition and stroke
Although most white matter lesions cause no immediate symptoms, they can certainly have consequences in the long run. Research shows that people with migraine who have many lesions more often develop subtle cognitive problems, especially in executive function and processing speed.
In addition, people with migraine, especially women under 45 with aura, have an increased risk of ischaemic stroke. In absolute numbers this risk is still relatively low, but it is statistically significant enough to take into account when making treatment decisions. That is why, if you have migraine with aura, you are typically advised against using the combined pill for contraception.
CGRP inhibitors?
Migraine is increasingly treated with CGRP inhibitors. Although they work for some people, a CGRP inhibitor does not resolve the cause of the migraine. After all, CGRP is a substance that only appears once the neuron has been in trouble for a long time. So it does not reduce the chance of damage in the brain. The underlying migraine attack can still take place, just without (or with less) throbbing pain.
So what can you do?
What you can do is remove additional risks for blood clotting.
The obvious ones are hormonal contraception (the combined pill) and smoking. But if we look at the other risk factors, we see high blood pressure, diabetes and abnormal cholesterol levels. These are all linked to a metabolic disruption, something you can influence a great deal with nutrition and other interventions.
Curious how we approach this at the Functional Migraine Clinic? Start with the Building Block Analysis.
