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      Migraine and cardiovascular disease: systematic review and meta-analysis


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          Objective To evaluate the association between migraine and cardiovascular disease, including stroke, myocardial infarction, and death due to cardiovascular disease.

          Design Systematic review and meta-analysis.

          Data sources Electronic databases (PubMed, Embase, Cochrane Library) and reference lists of included studies and reviews published until January 2009.

          Selection criteria Case-control and cohort studies investigating the association between any migraine or specific migraine subtypes and cardiovascular disease.

          Review methods Two investigators independently assessed eligibility of identified studies in a two step approach. Disagreements were resolved by consensus. Studies were grouped according to a priori categories on migraine and cardiovascular disease.

          Data extraction Two investigators extracted data. Pooled relative risks and 95% confidence intervals were calculated.

          Results Studies were heterogeneous for participant characteristics and definition of cardiovascular disease. Nine studies investigated the association between any migraine and ischaemic stroke (pooled relative risk 1.73, 95% confidence interval 1.31 to 2.29). Additional analyses indicated a significantly higher risk among people who had migraine with aura (2.16, 1.53 to 3.03) compared with people who had migraine without aura (1.23, 0.90 to 1.69; meta-regression for aura status P=0.02). Furthermore, results suggested a greater risk among women (2.08, 1.13 to 3.84) compared with men (1.37, 0.89 to 2.11). Age less than 45 years, smoking, and oral contraceptive use further increased the risk. Eight studies investigated the association between migraine and myocardial infarction (1.12, 0.95 to 1.32) and five between migraine and death due to cardiovascular disease (1.03, 0.79 to 1.34). Only one study investigated the association between women who had migraine with aura and myocardial infarction and death due to cardiovascular disease, showing a twofold increased risk.

          Conclusion Migraine is associated with a twofold increased risk of ischaemic stroke, which is only apparent among people who have migraine with aura. Our results also suggest a higher risk among women and risk was further magnified for people with migraine who were aged less than 45, smokers, and women who used oral contraceptives. We did not find an overall association between any migraine and myocardial infarction or death due to cardiovascular disease. Too few studies are available to reliably evaluate the impact of modifying factors, such as migraine aura, on these associations.

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          Most cited references21

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          Prevalence and burden of migraine in the United States: data from the American Migraine Study II.

          To describe the prevalence, sociodemographic profile, and the burden of migraine in the United States in 1999 and to compare results with the original American Migraine Study, a 1989 population-based study employing identical methods. A validated, self-administered questionnaire was mailed to a sample of 20 000 households in the United States. Each household member with severe headache was asked to respond to questions about symptoms, frequency, and severity of headaches and about headache-related disability. Diagnostic criteria for migraine were based on those of the International Headache Society. This report is restricted to individuals 12 years and older. Of the 43 527 age-eligible individuals, 29 727 responded to the questionnaire for a 68.3% response rate. The prevalence of migraine was 18.2% among females and 6.5% among males. Approximately 23% of households contained at least one member suffering from migraine. Migraine prevalence was higher in whites than in blacks and was inversely related to household income. Prevalence increased from aged 12 years to about aged 40 years and declined thereafter in both sexes. Fifty-three percent of respondents reported that their severe headaches caused substantial impairment in activities or required bed rest. Approximately 31% missed at least 1 day of work or school in the previous 3 months because of migraine; 51% reported that work or school productivity was reduced by at least 50%. Two methodologically identical national surveys in the United States conducted 10 years apart show that the prevalence and distribution of migraine have remained stable over the last decade. Migraine-associated disability remains substantial and pervasive. The number of migraineurs has increased from 23.6 million in 1989 to 27.9 million in 1999 commensurate with the growth of the population. Migraine is an important target for public health interventions because it is highly prevalent and disabling.
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            A note on graphical presentation of estimated odds ratios from several clinical trials.

            To display a number of estimates of a parameter obtained from different studies it is common practice to plot a sequence of confidence intervals. This can be useful but is often unsatisfactory. An alternative display is suggested which represents intervals as points on a bivariate graph, and which has advantages. When the data are estimates of odds ratios from studies with a binary response, it is argued that for either type of plot, a log scale should be used rather than a linear scale.
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                Author and article information

                Role: instructor
                Role: doctoral student
                Role: director
                Role: professor
                Role: professor
                Role: senior researcher
                BMJ : British Medical Journal
                BMJ Publishing Group Ltd.
                27 October 2009
                : 339
                : b3914
                [1 ]Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 900 Commonwealth Avenue East, Boston, MA 02215-1204, USA
                [2 ]Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
                [3 ]Department of Neurology, Albert Einstein College of Medicine, NY, USA
                [4 ]Merck Research Laboratories, Whitehouse Station, NJ, USA
                [5 ]Department of Epidemiology and Population Health, Albert Einstein College of Medicine, NY, USA
                [6 ]Montefiore Headache Center, Bronx, NY, USA
                [7 ]INSERM Unit 708—Neuroepidemiology, Paris, France
                [8 ]Faculty of Medicine, University Pierre et Marie Curie, Paris, France
                [9 ]Department of Neurology, University Hospital Essen, Germany
                Author notes
                Correspondence to: M Schürks mschuerks@ 123456rics.bwh.harvard.edu

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

                : 22 June 2009
                Smoking and tobacco
                Epidemiologic studies
                Drugs: cardiovascular system
                Headache (including migraine)
                Drugs: obstetrics and gynaecology
                Reproductive medicine
                Ischaemic heart disease
                Health education
                Health promotion



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