Source: Akavian I, Nitzan I, Twig G, et al. Association between migraine and hypertension in 2 million adolescents. Hypertension. 2025;82(11):e337-e345; doi: 10.1161/HYPERTENSIONAHA.125.24861.Investigators from multiple institutions in Israel conducted a retrospective study to assess the association between migraines and hypertension in adolescents. Study participants were individuals 16–20 years old undergoing health screening prior to mandatory military service in Israel between 1990 and 2019. As part of the health assessment, blood pressure (BP) was measured twice and the results averaged. For those with a systolic BP (SBP) >140 or diastolic BP (DBP) >90, an additional 10 BP measurements were obtained over a 3-week period. If SBP was >140 or DBP was >90 on at least 50% of the follow-up measurements, a diagnosis of hypertension was made, and a detailed examination was conducted to rule out secondary hypertension. Individuals with evidence of end-organ damage, or in whom hypertension remained uncontrolled, were categorized with high-severity hypertension. A diagnosis of migraine was made based on a history of headaches or migraines, followed by an assessment by a neurologist. Participants with recurrent migraine attacks leading to school or work absenteeism for >1 year were classified as having severe migraines. For the primary analysis, the risk of hypertension in study participants with a confirmed diagnosis of migraine was compared to those without migraine using logistic regression. Multiple confounders were included in the regression analysis. In a secondary analysis, the risk of high-severity, or lower-severity hypertension, in those with and without migraine was assessed. In addition, the risk of hypertension in participants with severe migraines, or less severe migraines, was compared with that of individuals without a diagnosis of migraine.Data on 2,155,077 military recruits were included in the analysis. The mean age of study participants was 17.2 ±0.5 years, and 58% were males. There were 61,314 (2.85%) participants with a diagnosis of migraine. Overall, 5,123 (0.2%) individuals in the study were diagnosed with hypertension. Among those with migraine, 0.7% had hypertension vs 0.2% of those without a diagnosis of migraine (adjusted odds ratio aOR, 3.01; 95% confidence interval CI, 2.72, 3.33). Compared to those without migraine, the risk of severe hypertension in participants with migraine was somewhat higher (aOR, 3.34; 95% CI, 2.92, 3.82) than in those with lower-severity hypertension (aOR, 2.67; 95% CI, 2.30, 3.10). Similarly, the risk of hypertension was higher for those with severe migraines (aOR, 4.41; 95% CI, 3.87, 5.03), than in adolescents with less severe migraines (aOR, 2.02; 95% CI, 1.77, 2.37).The authors conclude that adolescents with a diagnosis of migraine were at increased risk for hypertension.Dr Rhone has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.A common conundrum occurs when evaluating a child with headache and hypertension. Is pain causing BP elevation? Or is hypertension contributing to the headache itself?The current large, population-based study results suggest that these conditions could represent parallel manifestations of vascular vulnerability emerging early in life.Using 3 decades of Israeli pre-military medical screening data, the current authors found that hypertension was more common among adolescents with migraine than controls. Notably, the authors also identified dose-response relationships: Increasing migraine severity was associated with higher odds of hypertension, and migraine was more strongly linked to severe than mild hypertension. Although the cross-sectional design precludes causal inference and residual confounding remains possible, this parallel gradient supports a biologically meaningful association.Although historically conceptualized as a vascular disorder, migraine is now understood primarily as dysfunction of the trigeminovascular system, with vascular changes as secondary phenomena.1 However, hypertension is a risk factor for chronic transformation of episodic migraine, and genetic studies support shared vascular risk variants between migraine and cardiovascular disorders.2-4 The relationship between migraine and hypertension appears to be bidirectional and multifactorial, with shared pathophysiologic mechanisms including endothelial dysfunction, blood-brain barrier alterations, calcitonin gene-related peptide signaling, and reninangiotensin-aldosterone system dysregulation.2,3Previous investigations have identified vascular risk factors in pediatric patients with headache. A study of ~12,000 children and adolescents found that those with severe or recurrent headache had significantly higher mean values for body mass index, C-reactive protein, and homocysteine, and children with headache were more likely to be in the highest quintile of risk for multiple vascular markers.5 Ambulatory BP monitoring for children with migraine identified abnormal BP patterns in 46%, even when office BP measurements were normal.6For individual patients, answering the directionality question—whether headache causes hypertension or vice versa—will remain challenging. Yet, the results of this study suggest that clinicians should regard the overlap of migraine and hypertension as a potentially meaningful pattern indicative of increased long-term vascular risk.Migraine in adolescence, particularly when severe, is associated with hypertension.
A Sun, study studied this question.