Oral contraceptives, hormone replacement therapy and haemostasis

Hyperthyroidism and thrombophilia in cerebral arterial and venous thrombosis: a case report and critical review

INTRODUCTION

People with hyperthyroidism, thrombophilia, or oral contraceptive (OC) use are reported to have a risk in developing arterial or venous thrombosis. There has been a rare case reporting concurrent arterial and venous thrombosis in such patients.

CASE REPORT

We presented a 44-year-old woman with Grave disease and metabolic syndrome developing cerebral venous and arterial thrombosis and later deep vein thrombosis after OC use. At the acute stage, hyperthyroidism was associated with an increase in factor VIII and antithrombin III deficiency. At follow-up, antithrombin III level remained decreased. Her daughter with Hashimoto thyroiditis in a euthyroid state presenting with headache and OC use was also found to have antithrombin III deficiency.

CONCLUSIONS

Elevated factor VIII and antithrombin III deficiency were associated with a series of arterial and venous thrombotic events in this patient. Thyroid disease and OC use may have an impact on these coagulation parameters. We suggested that the exclusion of thrombophilia and of alterations of coagulative parameters should precede any decision of OC prescription in thyroid disease patient with a family history of venous thromboembolism.

Migraine and ischaemic heart disease and stroke: potential mechanisms and treatment implications

The migraine-ischemia relationship is best understood in the context of the pathophysiology of migraine. Potential mechanisms of migrainous infarction (stroke occurring during migraine) include vasospasm, hypercoagulability, and vascular changes related to cortical spreading depression. Stroke occurring remote for the migraine attack may be related to arterial dissection, cardioembolism, and endothelial dysfunction. Endothelial dysfunction, a process mediated by oxidative stress, may be a cause or a consequence of migraine, and explain the relationship of migraine to vascular factors and ischemic heart disease. It remains uncertain whether stroke or myocardial infarction can be prevented by migraine prophylaxis, endothelial repair, platelet inhibition, or a combination of these strategies. Although triptans are generally considered safe for use in migraine, caution is warranted in those with multiple vascular risk factors. Known vascular disease is a contraindication to triptan use.

The risk of stroke in patients with migraine and implications for migraine management

Assessing the risk of stroke in persons with migraine is complicated by the intricate relationship between these two conditions. Both migraine and stroke are common and co-morbidity may, in some cases, be coincidental. Given the overlap of clinical symptoms in stroke and migraine, each condition may also mimic the other. Numerous studies have, however, shown that migraine is an independent risk factor for stroke both during, and remote from, the migraine attack. Women of childbearing age and those with aura are at greatest risk of migraine-related stroke. Additional risk of stroke in migraineurs occurs in those using oral contraceptive pills and who smoke cigarettes. Elevated blood pressure, an important stroke risk factor, is less common in migraineurs. Acquired antiphospholipid antibodies, not clearly a cause of migraine per se, may raise the risk of infarction in migraineurs. Hereditary conditions, including CADASIL (cerebral autosomal dominant arteriopathy with sub-cortical infarcts and leukoencephalopathy), MELAS (mitochondrial myopathy, encephalopathy, lactacidosis and stroke) and hereditary haemorrhagic telangiectasia, appear to predispose to both migraine and stroke. Purported mechanisms for migraine-associated stroke include involvement of the vasculature (including vasospasm, arterial dissection and small vessel arteriopathy), hypercoagulability (elevated von Willebrand Factor, platelet activation) and elevated risk of cardioembolism (patent foramen ovale, atrial septal aneurysm). Triptans and ergotamines, used to treat acute migraine attacks, appear to be safe in low-risk populations. These medications should be avoided in persons with haemiplegic migraine, basilar migraine, vascular risk factor and prior cerebral or cardiac ischaemia.