ISC 2026 | The distinctive aspects of cardiovascular risk in women with migraine

There’s a very peculiar connection between stroke and migraine, and peculiarities are particularly important for women. Migraine is a well-known risk factor for stroke, especially for ischemic stroke, and among the different migraine subtypes, we have the strongest evidence for the migraine with aura. The risk is relatively low overall, so we don’t expect that that many women suffer from migraine with aura in the general population will get a stroke. But if we look at the population of young patients with ischemic stroke that are admitted to our stroke units, the impact of migraine is huge. Migraine is considered one of the leading risk factors in this population. It’s the fourth if we consider ranking of different risk factors, and it’s above hypertension and high LDL cholesterol. Recently, data from the SECRETO study were published in 2025, showing that migraine is the risk factor with the highest attributable population risk in young patients with cryptogenic stroke, and that the risk is different between those who have or have not a patent foramen ovale, and it’s much higher for women with migraine having a patent foramen ovale, and thus highlighting the importance of this combination in young patients with the cryptogenic stroke. The mechanism is not entirely clear, but we can suppose that the microembolism to the brain can either trigger cortical spreading depression, and thus migraine aura, and leading in some cases to ischemic stroke. The peculiarities regarding the Migraine-Stroke Association also refer to the use of combined hormonal contraceptives in women. There are guidelines that recommend against the use of the combined hormonal contraceptives in women with migraine, but the scientific data underlying this increased risk are not so strong, and recently this year a new study was published in Cephalalgia, a study based in the US, including a huge number of women using and not using combined hormonal contraceptives, and this study showed that in women using the hormonal contraceptive, even women with migraine with aura, there was no substantial increase in the risk, and I think that this is reassuring, and it’s also due to the fact that the contraceptives that are used nowadays are different from the ones that were used in the past. They include natural estrogens and also low-dose estrogens. And so I think that so far, the contraindication cannot be considered any more strong. Of course, caution is needed. If it’s possible to avoid them, I think it’s better to avoid them. But if a patient has medical conditions requiring combined hormonal contraceptives, I think there are no solid reasons to deny this treatment. And the last aspect that I want to highlight is the association between migraine and adverse events associated with pregnancy. Again, this is an area of particular interest because there are data from many different studies that unanimously indicate that women with migraine have an increased risk of eclampsia and preeclampsia, but also vascular events and mostly stroke, and again, a study published this year indicated that the risk mostly refers to women with migraine with aura. And so the take-home message, I think, in this sense, is that in women with migraine who get pregnant, we need to be more vigilant about possible risks related to pregnancy.

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