Age Emerges as the Strongest MRI Signal in Migraine Cohort
Migraine clinics still wrestle with a familiar question: who actually needs brain MRI? In a large tertiary headache-unit cohort, white matter lesions and silent brain infarcts were common enough to keep that question clinically relevant, but the clearest signal came from age rather than migraine phenotype itself.
The study evaluated 768 patients seen at a tertiary headache unit over a two-month period in 2024, and 378 of them underwent brain MRI and had no prior cerebrovascular disease. Among those scanned, 82 had white matter lesions and 10 had silent brain infarcts, together accounting for 24% of the MRI cohort. In a field where imaging is often reserved for atypical presentations, these findings sharpen the debate around which bedside clues should prompt a scan.
One sentence stood out in practical terms: older age tracked with both lesion types.
Structural Brain Findings Were Not Rare in the Imaged Subgroup
The MRI findings fit a pattern neurologists have seen repeatedly in migraine populations: incidental structural abnormalities are common, but not always easy to interpret. White matter lesions are often nonspecific and can reflect small-vessel vulnerability, cumulative vascular burden, or age-related change rather than migraine pathology alone. Silent brain infarcts raise a more consequential concern because they imply previous ischemic injury without a recognized clinical stroke.
In this cohort, the combined prevalence of these findings among imaged patients reached nearly one in four. That number does not mean migraine itself caused the lesions, and it does not justify indiscriminate imaging. It does mean structural abnormalities are common enough that clinicians cannot dismiss MRI abnormalities as vanishingly rare in tertiary migraine care.
The study focused on identifying clinical “red flags” that could improve MRI selection. Demographic variables, vascular risk factors, and migraine characteristics were examined, including aura status and whether the disorder was episodic or chronic. Univariate analyses linked white matter lesions with older age and dyslipidaemia, while tobacco use showed a borderline association. Silent brain infarcts were associated with older age and hypertension.
Vascular Risk Factors Outweighed Migraine Phenotype
The most clinically interesting message is not the presence of lesions, but the way they distributed across risk profiles. Migraine-specific features did not dominate the analysis. Instead, traditional vascular biology appeared to drive much of the signal, especially for ischemic-appearing injury. Age remained independently associated with white matter lesions after multivariable adjustment, while vascular risk factors and migraine characteristics lost clear predictive power in that model.
That pattern makes biological sense. White matter lesions and silent infarcts are more plausibly linked to cumulative endothelial dysfunction, microvascular remodeling, and long-term blood pressure or lipid burden than to aura alone. Migraine may coexist with these abnormalities, but the MRI findings in this cohort appear to behave more like markers of vascular aging than as simple signatures of headache subtype.
Hypertension aligned with silent brain infarcts, which fits the established relationship between elevated blood pressure and small-vessel ischemic injury. Dyslipidaemia’s association with white matter lesions also points toward a vascular substrate, even if the independent effect disappeared after adjustment. Tobacco use, although only borderline in univariate testing, still belongs in the clinician’s mental checklist when deciding whether imaging is warranted.
MRI Requests May Need to Follow Risk, Not Headache Labels
This is where the bedside implications become immediate. A patient with migraine, particularly an older one with vascular risk factors, does not fit the same imaging logic as a younger patient with a stable migraine pattern and no comorbid vascular burden. The study supports a more selective approach that weighs age and vascular risk more heavily than migraine phenotype alone.
The data also argue against overreliance on aura as a stand-alone imaging trigger. Aura remains clinically important, but in this cohort it did not emerge as the dominant determinant of MRI abnormalities. A headache history alone was not enough to separate patients with structural lesions from those without them.
For a tertiary headache unit, the message is operational as well as diagnostic. MRI can clarify whether lesions reflect incidental age-related change or something more concerning, but the scan should be ordered with a risk-based rationale. In a population where nearly a quarter of scanned patients had white matter lesions or silent infarcts, imaging restraint still matters; so does not missing the subgroup in whom vascular disease is hiding behind a migraine label.
Why Silent Brain Infarcts Carry More Weight Than White Matter Lesions
White matter lesions are common and often nonspecific. Silent brain infarcts are different. Even without overt neurological symptoms, infarcts mark prior tissue injury and can carry implications for future cerebrovascular risk assessment. Their association with older age and hypertension in this study is consistent with a small-vessel ischemic mechanism, and it strengthens the case for taking vascular optimization seriously when these findings appear on MRI.
A major strength of the study is the real-world tertiary headache setting, where the clinical question arises exactly as it does in practice. The limitation is equally clear: this was a single-center retrospective study, and multivariable modeling was not performed for silent brain infarcts because too few cases were available. The MRI cohort also represented only the subset who were scanned, so the findings should not be generalized to every patient with migraine.
Even so, the message is coherent. In migraine, brain MRI abnormalities track more strongly with age and vascular burden than with headache phenotype alone. For clinicians deciding whether to request imaging, that shifts attention toward the patient’s vascular profile, not just the character of the headache.