Role of Magnetic Resonance Imaging in The Diagnosis of Stroke in Patients Presenting with Migraine

Background: Migraine with aura increases the risk of ischemic stroke; however, migraine itself does not directly cause stroke. Magnetic resonance imaging (MRI) has a vital role as a diagnostic tool for the investigation of life-threatening conditions mimicking migraine and is also used to study the link between severe migraines and strokes. Differentiating true cerebrovascular events from migraine-associated neurological symptoms remains a major diagnostic challenge in clinical practice, particularly in developing countries where detailed radiological data on this overlap are scarce. Objectives: To evaluate the role of MRI in the diagnosis of stroke in patients presenting with migraine; specifically, to determine the frequency of stroke detected on MRI in migraine patients, to determine the association between migraine-related clinical risk factors and the occurrence of stroke on MRI, and to identify the role of individual MRI sequences in early stroke diagnosis. Methods: We conducted an analytical cross-sectional study in the Neurology Department of Rehman Medical Institute (RMI), Peshawar, Pakistan. A total of 384 patients with a confirmed diagnosis of migraine were enrolled using a non-probability convenience sampling technique. We collected data on demographic characteristics, migraine features, and clinical risk factors using a structured proforma, and all participants underwent brain MRI with T1-weighted, T2-weighted, FLAIR, DWI, ADC, and GRE/SWI sequences. We analysed data using IBM SPSS version 27, with descriptive statistics, the Chi-square test, and binary logistic regression; p < 0.05 was considered statistically significant. Results: Stroke was detected on MRI in 27.9% (n = 107) of the patients presenting with migraine, of which 90.7% were ischemic and 9.3% showed hemorrhagic transformation. Migraine with aura was significantly associated with the occurrence of stroke and emerged as the strongest independent predictor on multivariable analysis (adjusted odds ratio [AOR] = 3.25, 95% CI: 1.85–5.71, p < 0.001), followed by hypertension (AOR = 2.90, 95% CI: 1.62–5.18, p < 0.001) and smoking (AOR = 2.15, 95% CI: 1.12–4.12, p = 0.021). Diffusion-weighted imaging showed the highest sensitivity for acute infarct detection (100%), followed by ADC mapping (96.3%), while FLAIR and GRE/SWI sequences provided important complementary information on infarct age, edema, and hemorrhagic transformation. Conclusions: The findings confirm that MRI, particularly the combination of DWI and ADC sequences, plays a critical role in the accurate diagnosis of stroke among patients presenting with migraine and that migraine with aura, hypertension, and smoking are significant clinical predictors of stroke in this population. Early and appropriate use of MRI in migraine patients with these risk factors can improve diagnostic accuracy and support timely clinical management.