Migraine, Heart Attack, and Stroke Before and After Menopause: What a 2.2 Million-Woman Study Found

Why This Study Was Done

Migraine, especially migraine with aura, has been tied to a higher risk of heart attack and ischemic stroke in women for years. Most of that research focused on younger women, when baseline cardiovascular risk is low. After menopause, everyone's risk climbs as estrogen falls and blood pressure, cholesterol, and blood sugar tend to rise. That leaves an open question: does migraine still add risk once menopause has already raised the floor, and how should that extra risk be described?

A team in South Korea used national health insurance records to answer this directly. Their study, published in The Journal of Headache and Pain, compared women with and without migraine separately before and after menopause, and reported the results two ways: as a relative risk and as an absolute difference in how many events occurred.

It builds on an earlier Women's Health Initiative study we covered, which looked only at postmenopausal women and only at stroke. You can read that summary in our article on migraine and stroke risk after menopause.

How the Study Was Done

This was a nationwide cohort study. The researchers started with women aged 40 and older who attended Korea's national health screening and cancer screening programs in 2009. They excluded anyone with a prior heart attack or ischemic stroke, anyone who had a hysterectomy, and anyone missing key screening or reproductive data.

Migraine was defined as at least one insurance claim with a migraine diagnosis code in the year before the 2009 exam. That identified 35,139 premenopausal women (3.8%) and 57,489 postmenopausal women (4.7%) with migraine. Menopausal status came from a screening questionnaire.

The main outcome was cardiovascular disease, defined as a combination of hospital-recorded heart attack and ischemic stroke. Cardiovascular death was a secondary outcome. The team adjusted for age, body mass index, income, smoking, alcohol, exercise, high blood pressure, diabetes, high cholesterol, kidney disease, atrial fibrillation, and reproductive factors such as age at first period, number of births, breastfeeding, and oral contraceptive use. Hormone therapy use was also included for postmenopausal women.

What the Study Found

Women with migraine had more heart attacks and ischemic strokes than women without migraine, both before and after menopause. The way that excess showed up depended on menopausal status.

Fully adjusted models. Numbers in parentheses are 95% confidence intervals.

On the relative scale, migraine was linked to about a 53% higher risk of heart attack or ischemic stroke before menopause and about a 20% higher risk after menopause. The pattern was similar for heart attack and ischemic stroke when each was looked at on its own.

Absolute Differences

Because cardiovascular events are much more common after menopause, the smaller relative increase turned into more extra events. The researchers reported raw event rates per 1,000 person-years, which you can read as roughly the number of events per 1,000 women per year.

Heart attack or ischemic stroke combined. These are crude (unadjusted) rates.

So a premenopausal woman with migraine starts from a low baseline, and migraine raises it proportionally more. A postmenopausal woman with migraine starts from a much higher baseline, and migraine adds a smaller percentage on top, but that percentage translates into more than twice as many extra events per 1,000 women each year.

Migraine With Aura

Women with a diagnosis code for migraine with aura had numerically higher estimates for heart attack, ischemic stroke, and the combined outcome than the migraine group overall, in both menopausal groups. That fits years of research pointing to aura as the higher-risk migraine type. The exact aura figures are in the paper's supplementary tables.

Other Findings

The link held when the researchers used a 2-year window to define migraine and when they limited follow-up to 5 years. In exploratory subgroup analyses, the association pointed the same direction across age groups and cardiovascular risk profiles. The relative link looked somewhat stronger among postmenopausal women using hormone therapy, but the authors caution that they had no data on hormone type, dose, route, or timing, so this says nothing about whether hormone therapy itself changes risk.

Limitations to Keep in Mind

This is an observational study, so it shows an association, not proof that migraine causes heart attacks or strokes. The authors adjusted for many factors, but confounding by things they could not measure is still possible.

• Migraine was identified from insurance codes. Women who never saw a clinician for migraine were counted as not having it, and the data could not separate active migraine from past migraine. There was no information on attack frequency, severity, or treatment.
• Menopausal status came from a single questionnaire. It did not confirm 12 months without a period, and some women counted as premenopausal likely went through menopause during follow-up.
• The population was Korean. Results may differ in populations with different backgrounds and health systems.
• Women with missing data were excluded. They tended to be older with more cardiometabolic risk factors, so the analyzed group may be somewhat healthier than average, which could lower the absolute event rates.
• The absolute differences are crude. The extra events per 1,000 women come from unadjusted rates, while the hazard ratios are adjusted.

The authors also note that mixing up menopausal groups would most likely blur the difference between them, so the true gap in relative risk could be larger than what they measured.

What This Means for People With Migraine

This study adds to evidence that migraine belongs on the list of cardiovascular risk factors for women at every stage of life, including after menopause. It does not mean that any one woman with migraine will have a heart attack or stroke. Even after menopause, the large majority of women with migraine in this study did not have one in a given year.

In practice, make sure your migraine history, and whether you have aura, is part of your cardiovascular risk discussion. That matters most during the menopausal transition, when migraine itself often shifts. Our article on whether migraine goes away after menopause covers who tends to keep having attacks.

High blood pressure, smoking, diabetes, and high cholesterol drive most cardiovascular events, and they respond to treatment. Our overview of stroke prevention in people with migraine walks through those steps, and our broader piece on migraine and cardiovascular disease explains the proposed mechanisms.

If you take a CGRP-targeting preventive, a recent study we covered found no greater rise in blood pressure over 12 months than in matched controls, though erenumab (Aimovig) carries a label warning about hypertension. You can read our summary of the CGRP and blood pressure study for details.

Hormonal changes across the life course shape migraine in many ways, which we cover in migraine, menopause, and hormonal health. To bring your aura history, attack pattern, and current medications to your next visit in one place, try our printable migraine appointment summary sheet.

Key Takeaways