In women, migraine with aura is a risk factor for several ischaemic outcomes including all cause cardiovascular death, stroke, myocardial infarction, angina, coronary revascularisation procedures, and claudication.1 2 3 4 This has led to the suggestion that migraine with aura may predispose to systemic atherosclerosis, which increases the risk for each of these outcomes through similar mechanisms.

In the linked cohort study (doi: 10.1136/bmj.a636), Kurth and colleagues assess whether migraine with aura may be linked to stroke and myocardial infarction through distinct mechanisms.1 They show that in women, the relation of migraine with aura to subsequent stroke and myocardial infarction depends on cardiovascular risk as estimated by the Framingham risk score.1 Their findings raise questions regarding the mechanistic links between migraine with aura, stroke, and myocardial infarction and have implications for clinical practice and preventive interventions.

Abundant evidence indicates that the aura of migraine is underpinned by cortical spreading depression, which is a neuronal and a glial event.5 6 7 8 Cortical spreading depression …