AURA-STROKE: a perspective on developing a multimodal stroke risk prediction framework for migraine patients

Migraine, particularly migraine with aura, is an established independent risk factor for ischemic stroke, yet the absence of effective risk stratification tools prevents targeted primary prevention in this large, vulnerable population. This perspective article proposes the AURA-STROKE initiative: a conceptual framework for integrating retinal vascular imaging through optical coherence tomography angiography (OCTA) with traditional clinical and emerging genetic risk factors. The retina offers a unique non-invasive window to cerebral microvasculature, and recent evidence suggests that quantifiable retinal microvascular changes in migraine patients may reflect systemic vasculopathy linked to stroke risk. We advocate for a large-scale, multicenter, prospective cohort study with 10-year follow-up to develop and validate a multimodal stroke risk prediction model specifically for migraine patients. Such a study would leverage Taiwan’s National Health Insurance Research Database for near-complete outcome ascertainment and employ rigorous statistical methods including Cox proportional hazards modeling with LASSO regularization and competing risk analysis. The successful development of this clinically pragmatic risk stratification tool could substantially advance personalized preventive neurology, potentially enabling physicians to identify high-risk migraine patients who would benefit from intensified stroke prevention strategies. This perspective outlines the compelling rationale, proposed methodological framework, and anticipated impact of this critical research endeavor.