Migraine with aura has limited utility for risk stratification of CVD

Migraine with aura is linked with cardiovascular disease independent from traditional vascular risk factors. However, there is no clarity on the importance of MA in CVD occurrence compared to existing cardiovascular prediction tools. Therefore, Pamela M. Rist, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA, and colleagues sought to determine if adding migraine with aura status to two CVD risk prediction models improves risk prediction.

The researchers identified 24,493 women (average age around 54 years) with self-reported MA status enrolled in the Women's Health Study and were followed for incident CVD events. Among them, 5.1% reported migraines with aura at baseline; these people tended to be slightly younger and were suitable to have higher C-reactive protein values, a family history of myocardial infarction (MI), and no history of diabetes.

The authors included MA status as a covariable in the American College of Cardiology (ACC)/American Heart Association (AHA) pooled cohort equation and the Reynolds Risk Score. They assessed discrimination (Harrell c-index), integrated discrimination improvement (IDI), and continuous and categorical net reclassification improvement (NRI).

The authors reported the following findings:

• MA status was significantly associated with cardiovascular disease after including covariables in the Reynolds Risk Score (HR: 2.09) and the AHA/ACC score (HR: 2.10).
• Adding information on MA status improved discrimination of the Reynolds Risk Score model (from 0.792 to 0.797) and the AHA/ACC score model (from 0.793 to 0.798).
• After adding MA status to both models, a small but statistically significant improvement in the IDI and continuous NRI was observed.
• Significant improvements in the categorical NRI were not seen.

In an accompanying editorial, Angela A. Stanton, PhD Stanton Migraine Protocol Inc, Anaheim, CA, opens the door to the idea that there's much left to be learned about what characteristics drive CVD risk and stresses the need to separate causation from the association.

"Surprisingly, migraine with aura did not improve net reclassification," she writes, but the silver lining of this finding is that we can cross it off the list of risk factors that predict CVD. Or can we? she questions.

"Adding information on migraine with aura status to commonly used CVD risk prediction algorithms enhanced model fit but did not remarkably improve risk stratification among women," the study authors wrote.

"Despite the strong association of migraine with CVD risk, its usefulness in improving risk classification at the population level gets limited by the relatively low prevalence of MA compared with other CV risk factors," they concluded.

Reference:

Rist, P. M., Buring, J. E., Cook, N. R., & Kurth, T. (2023). Contribution of Migraine to Cardiovascular Disease Risk Prediction. Journal of the American College of Cardiology, 81(23), 2246-2254. https://doi.org/10.1016/j.jacc.2023.03.429