Being vigilant about these unexpected risk factors could save your life

What if there were more to preventing a stroke than keeping your blood pressure under control…getting regular exercise…watching your body weight…and not smoking? Researchers are now discovering that there is.

New thinking: While most stroke sufferers say that “it just came out of the blue,” an increasing body of evidence shows that these potentially devastating “brain attacks” can be caused by conditions that you might ordinarily think are completely unrelated.

Once you’re aware of these “hidden” risk factors—and take the necessary steps to prevent or control them—you can improve your odds of never having a stroke. Recently discovered stroke risk factors…


Both Crohn’s disease and ulcerative colitis can severely damage the large or small intestine. But that is not the only risk. Among patients who have either one of these conditions, known as inflammatory bowel disease (IBD), stroke is the third-most-common cause of death, according to some estimates.

During flare-ups, patients with IBD have elevated blood levels of substances that trigger clots—the cause of most strokes. A Harvard study, for example, found that many IBD patients have high levels of C-reactive protein (CRP), an inflammatory marker that has been linked to atherosclerotic lesions, damaged areas in blood vessels that can lead to stroke-causing clots in the brain.

If you have IBD: Ask your doctor what you can do to reduce your risk for blood clots and inflammation. Some patients with IBD can’t take aspirin or other anticlotting drugs because these medications frequently cause intestinal bleeding. Instead of aspirin, you might be advised to take an autoimmune medication such as azathioprine (Azasan, Imuran), which suppresses the immune system and reduces inflammation. During flare-ups, some patients are given steroids to further reduce inflammation.

Side effects, including nausea and vomiting with azathioprine use and weight gain and increased blood pressure with steroid use, usually can be minimized by taking the lowest possible dose.

Some physicians recommend omega-3 fish oil supplements for IBD, which are less likely to cause side effects. Ask your doctor whether these supplements (and what dose) are right for you.

Important: Strokes tend to occur in IBD patients when inflammation is most severe. To check inflammatory markers, CRP levels and erythrocyte sedimentation rate (ESR) can be measured. Tests for clotting include fibrinogen and d-dimer. The results of these tests will help determine the course of the patient’s IBD treatment.


Migraine headaches accompanied by auras (characterized by the appearance of flashing lights or other visual disturbances) are actually a greater risk factor for stroke than obesity, smoking or diabetes (see below), according to a startling study presented at the American Academy of Neurology’s annual meeting earlier this year.

When researchers use MRIs to examine blood vessels in the brain, they find more tiny areas of arterial damage in patients who have migraines with auras than in those who don’t get migraines. (Research shows that there is no link between stroke and migraines that aren’t accompanied by auras.)

If you have migraines with auras: Reduce your risk by controlling other stroke risk factors—don’t smoke…lose weight if you’re overweight…and control cholesterol levels.

Also: Women under age 50 who have migraines (with or without auras) may be advised to not use combined-hormone forms of birth control pills—they slightly increase risk for stroke. In addition, patients who have migraines with auras should not take beta-blockers, such as propranolol (Inderal), or the triptan drugs, such as sumatriptan (Imitrex), commonly used for migraine headaches. These drugs can also increase stroke risk. For frequent migraines with auras, I often prescribe the blood pressure drug verapamil (Calan) and a daily 325-mg aspirin. Ask your doctor for advice.


Rheumatoid arthritis, unlike the common “wear-and-tear” variety (osteoarthritis), is an autoimmune disease that not only causes inflammation in the joints but may also trigger it in the heart, blood vessels and other parts of the body.

Arterial inflammation increases the risk for blood clots, heart attack and stroke. In fact, patients with severe rheumatoid arthritis were almost twice as likely to have a stroke as those without the disease, according to a study published in Arthritis Care & Research.

If you have rheumatoid arthritis: Work with your rheumatologist to manage flare-ups and reduce systemic inflammation. Your doctor will probably recommend that you take one or more anti-inflammatory painkillers, such as ibuprofen (Motrin). In addition, he/she might prescribe a disease-modifying antirheumatic drug (DMARD), such as methotrexate (Trexall), to slow the progression of the disease—and the increased risk for stroke. Fish oil also may be prescribed to reduce joint tenderness.

Strokes tend to occur in rheumatoid arthritis patients when inflammation is peaking. Ask your doctor if you should have the inflammation tests (CRP and ESR) mentioned in the IBD section.


If you have diabetes or diabetes risk factors—such as obesity, a sedentary lifestyle or a family history of diabetes—protect yourself. People with diabetes are up to four times more likely to have a stroke than those without it.

High blood sugar in people with diabetes damages blood vessels throughout the body, including in the brain. The damage can lead to both ischemic (clot-related) and hemorrhagic (bleeding) strokes.

If you have diabetes: Work closely with your doctor. Patients who achieve good glucose control with oral medications and/or insulin are much less likely to suffer from vascular damage.

Also important: Lose weight if you need to. Weight loss combined with exercise helps your body metabolize blood sugar more efficiently. In those with mild diabetes, weight loss combined with exercise may restore normal blood sugar levels…and can reduce complications and the need for medications in those with more serious diabetes.


Any condition that affects the blood’s normal clotting functions can increase risk for stroke. Examples: Thrombocytosis (excessive platelets in the blood)…an elevated hematocrit (higher-than-normal percentage of red blood cells)…or Factor V Leiden (an inherited tendency to form blood clots). Clotting tests (fibrinogen and d-dimer) are recommended for these disorders.

If you have a clotting disorder: Ask your doctor what you can do to protect yourself from stroke. Example: If you have an elevated hematocrit, your doctor might advise you to drink more fluids.

This is particularly important for older adults, who tend to drink less later in the day because they don’t want to get up at night to urinate. I recommend that these patients drink approximately 80 ounces of noncaffeine-containing fluids during the day, stopping by 7 pm. People who don’t take in enough fluids can develop “thick” blood that impedes circulation—and increases the risk for clots.