Review Elucidates Association Between Headache Disorders, Cognitive Impairment


Worse cognitive performance was seen among children prior to migraine attack onset compared with those who never developed migraine.

In a recently published narrative review, authors outlined research on potential associations between primary and secondary headache disorders and cognitive impairment.

Headache disorders have a lifetime prevalence of more than 90% while some conditions associated with cognitive decline may initially present with headaches, they explained.

The investigators carried out their review by searching PubMed from inception through October 2021 for relevant studies. Any articles assessing cognitive function during a primary headache attack were excluded from the final sample.

Evidence collected up to 2018 revealed “an association between worse performance in verbal comprehension, attention, and school grades in children before the onset of migraine attacks compared to peers who did not develop migraine later,” the authors wrote. This finding suggests “that cognitive dysfunction may be associated with a predisposition to later develop migraine and not the consequence of migraine attacks.”

In addition, worse performance with regard to attention, calculation, orientation, executive function, language, psychomotor speed, visuo-constructive skills, and memory in the first 50 years of life were linked with migraine.

However, strong evidence supporting a link between the condition and age-related cognitive decline was not found, while “7 large prospective studies support that migraine is not associated with dementia.”

Differences in study design, samples, and type of data reported limit meta-analyses on the association between migraine and cognitive decline, the researchers cautioned. Studies were also conducted among patients of various ages, which inhibits some generalizability.

In one analysis of 13-case controlled studies of young adult migraineurs, the researchers found an association between migraine and lower performance in memory, attention, psychomotor speed, and executive function; depression and anxiety and acute and preventive medication use did not affect this relationship.

Literature also does not support any link between deep white matter intensities—often seen in migraineurs via radiographic brain lesions on MRI—and cognitive function.

Limited data exist on cognitive dysfunction and familial hemiplegic migraine and on the potential association between tension-type headaches and cognitive impairment, the authors wrote.

“Given the high lifetime prevalence of tension-type headaches, uncovering a specific risk would be methodologically challenging and presumably very nonspecific,” they added.

Few studies also exist assessing any link between cluster headache and cognition.

When it comes to genetic vasculopathies, several forms of headache and cognitive decline have been reported among patients with the following conditions:

  • Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy
  • Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes
  • Cerebral amyloid angiopathy (CAA)
  • Syndrome of retinal vasculopathy with cerebral leukoencephalopathy and systemic manifestations
  • Moyamoya angiopathy

Furthermore, numerous studies have documented reports of headaches attributed to giant cell arteritis (GCA), stroke-like migraine attack after radiation therapy syndrome, posterior reversible encephalopathy syndrome, and reversible cerebral vasoconstrictive syndrome.

“More studies are needed to evaluate for potential long-term cognitive impairments related to PRES and RCVS specifically, relative to the associated risk,” the researchers wrote.

Both headache and cognitive impairments have been exhibited by patients with sickle cell disease, with tension-type headache and migraine being the most commonly reported phenotypes in this patient population. Processing speed and executive function are the main cognitive impairments reported in patients with sickle cell disease, and there are currently no standard proven strategies to prevent or improve the cognitive impairment in these patients.

Among individuals with postconcussion syndrome, posttraumatic headaches (PTHs) typically resemble migraine and tension-type headaches. According to the authors, “PTHs are noticed late in the course of severe traumatic brain injury once there has already been some recovery, while PTHs are present early in the course of mild traumatic brain injury.”

PTHs are associated with poorer neuropsychological testing scores and cognitive dysfunction, especially in attention, memory, and processing speed early in the posttraumatic course, they noted.

However, numerous postconcussion symptoms make it difficult to tease out any specific association between PTH sand cognition. No evidence was found linking PTHs with cognitive impairment in the long term.

Currently, a standardized validated test for interictal cognitive assessment of young adults with headache diseases does not exist. As such, the authors said they cannot recommend a specific cognitive test to use based on data assessed.

“It would also be helpful to assess whether the sleep disorders comorbid with migraine are associated with objective cognitive impairments,” they wrote.

Overall, “it is crucial to recognize the potentially reversible dementias associated with secondary headache disorders such as GCA- and CAA-related inflammation to attempt treatment rapidly,” added the authors.

In addition, “it is important to note that postural headaches tend to be the first symptom of frontotemporal brain sagging syndrome,” they said. For this reason, health care providers should consider performing brain imaging in patients with postural headache to assess for stigmata of spontaneous intracranial hypotension, they concluded.


Begasse de Dhaem O, Robbins MS. Cognitive impairment in primary and secondary headache disorders. Curr Pain Headache Rep. Published online March 3, 2022. doi:10.1007/s11916-022-01039-5

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