The Medical Risk EVERY 20-Something Should Know About

Illustrated by Mallory Heyer.
When 24-year-old Alleigh Marré came down with an excruciating headache one morning at work in August 2012, she didn’t think much of it. Marré was under a lot of stress as the press secretary for Massachusetts Sen. Scott Brown’s re-election campaign. “I thought, okay, I’m spending 16 to 18 hours in the office every day, it’s summer, it’s hot — this is a migraine,” she recalls. Marré tried to text her boss, who was out, to ask for the rest of the morning off, but her texts made no sense; she tried calling him, but she could hardly speak.

Upset, Marré went home to her Boston apartment, called her primary care doctor, who confirmed it was probably a migraine, and took a nap. When she awoke a few hours later, her headache was worse — “I can’t even put into words how bad it hurt,” she says — so she took herself to the hospital. Doctors there promptly put her into a CAT scan, a machine that allowed them to peer inside her skull. The next thing she knew, she was told she had suffered two strokes.

Marré’s terrifying experience is more common than it used to be: From 1995 to 2008, the number of women aged 15 to 34 who were hospitalized for stroke rose by 23%, according to a study published by researchers at the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta. (Meanwhile, stroke rates fell by 29% in women over 45.) Although some of this increase may be due to better stroke awareness and detection — more people with stroke symptoms are given MRI or CAT scans for proper diagnosis — “there is no question that there have been more strokes happening among the young," says Brett Kissela, MD, a neurologist at the University of Cincinnati.

Worse, one in every five women between the ages of 18 and 50 who suffers a stroke dies from it, in part because doctors don’t always think of strokes when they see young women — they think of strokes as conditions that primarily affect older people, particularly those who are overweight or have heart disease. Because of this, doctors sometimes mistake stroke symptoms like slurred speech and walking difficulties for alcohol or drug intoxication in young people. Ultimately, nearly twice as many women die from strokes every year than from breast cancer. As one study published in the journal The Lancet Neurology put it, “stroke has a greater effect on women than men because women have more events and are less likely to recover.”

A stroke cuts off vital blood flow to the brain, which is why it can be so debilitating. “Your brain needs blood all the time, and if it doesn’t get it, it stops functioning within minutes,” says John Cole, MD, a neurologist at the University of Maryland School of Medicine.

The most common type of stroke — in both young women and the general population — is an ischemic stroke, caused by a clot or severe narrowing in a blood vessel carrying blood to the brain. These types of strokes can be treated with a clot-busting drug called tissue plasminogen activator (tPA) that restores proper blood flow, reducing the risk of complications. Because they’re so easy to treat, ischemic strokes are less dangerous than rarer hemorrhagic strokes, which occur when blood vessels rupture and leak blood into the brain (treating these can involve surgery or transfusions). But there’s a big caveat with the clot-busting drug: It only works if it is administered within three hours of stroke onset, and the sooner it is given, the better. Marré was lucky — although she didn’t get the drug in time, the only complication she suffered was a temporary loss of peripheral vision. (About one-quarter of stroke survivors are left with minor disabilities, while 40% suffer moderate to severe complications.)

Hughes passed out, and she woke up a week and a half later — she had suffered a stroke.

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But why did she have a stroke at all? Marré, a marathon runner, didn’t have the obvious risk factors like high blood pressure or high cholesterol, and she wasn’t overweight. These conditions are known to increase stroke risk because they damage blood vessels and make it more likely for clots or tears to develop. (The high incidence of hypertension among young African-Americans could help explain why they are three times more likely than young whites to suffer strokes.) Smoking — both cigarettes and, some research suggests, marijuana — and taking drugs like cocaine and speed damage the lining of the arteries in ways that might increase stroke risk, too, but Marré didn’t do either.

Marre did, however, have other stroke risk factors. After her stroke, she learned she had a rare heart condition and problems with her arteries, which likely played a big role. She was also taking birth control, and she occasionally got migraine headaches, which may have contributed, too. A 2015 systematic review of 24 studies found that women who take birth control pills containing 50 micrograms of synthetic estrogen (this includes brand names that are followed by “1/50” like Ortho-Novum 1/50 and Demulen 1/50) are twice as likely to have a stroke as women who don't. Doctors suspect that the pill affects hormones in ways that make blood clots more common. In addition, women are two to three times as likely to have high blood pressure when they are taking the pill, although it’s unclear exactly why.

Women who have ever had migraines — particularly those who get strange visual symptoms known as auras before the headaches start — also have double the risk of stroke compared to women who don’t get these headaches, in part because migraines cause blood vessels to become inflamed, which can cause plaques to develop. Unfortunately, women like Marré who have migraines and take birth control pills are at an eight-fold higher risk for strokes than other women are. Add smoking to the mix, and a woman’s stroke risk skyrockets to 14 to 16 times higher than average.

And then there’s pregnancy. In 2006, a week after giving birth to a healthy baby boy, 25-year-old Rachel Hughes woke up from a nap in her home in Lansing, MI, with a terrible headache. When it didn’t go away and Hughes began seeing stars, she asked her mother, who was staying with her, to take her to the emergency room. While they waited to see a doctor, Hughes's arm started tingling, and she turned to her mom to tell her. “The only thing that would come out was "My arm feels like um, my arm feels like um, my arm feels like um,’” she recalls. She knew what she wanted to say, but she couldn’t actually say it. Eventually, Hughes passed out, and she woke up a week and a half later — she had suffered a stroke and, to give her brain time to heal, doctors had put her in a medically induced coma.
Like Marré, Hughes didn’t have high blood pressure or any of the common risk factors for stroke. But pregnancy itself increases risk — women who are pregnant or have just given birth are 2.4 times more likely than others to suffer a stroke — and pregnancy-related strokes are also becoming more common. Between 1994 and 2007, stroke hospitalizations for women who had recently given birth rose a whopping 83%, according to researchers at the CDC. “The fact that the numbers are growing — and drastically growing — is alarming,” says study author Elena Kuklina, PhD, a nutritional epidemiologist at the CDC. Although researchers don’t know exactly why they’re becoming more common, Dr. Kuklina says that it’s probably related to the fact that more young women these days are overweight or have diabetes, hypertension or other chronic conditions before they get pregnant, which increases stroke risk. Women who have high blood pressure during pregnancy, known as preeclampsia, are at an especially high risk. But even seemingly healthy women like Hughes are more likely to suffer strokes immediately after birth because the body goes through sudden postpartum hormonal changes that can affect the way blood vessels function.
Illustrated by Mallory Heyer.
But there is good news in all of this. First, stroke is still quite rare among young women, afflicting only 1 in 142 women between the ages of 20 and 39. And “stroke is a preventable disease, for the most part,” Dr. Cole says. Reducing your risk involves all of the usual stuff: First, eat well— a recent Harvard study found that eating five servings of fruits or vegetables a day was linked to a 30% drop in stroke risk. Perhaps even consider a Mediterranean diet rich in olive oil and nuts, as a 2012 clinical trial found that people who followed this diet were half as likely to suffer a stroke as others were. Try to exercise moderately five days a week, too: One meta-analysis found that frequent exercisers are 27% less likely to suffer strokes than sedentary people are. Finally, manage your blood pressure and cholesterol, as when they are high, stroke risk is too.

And what about the pill? For women who don’t smoke, have high blood pressure or have migraines, “the risk of the pill causing a stroke is pretty low,” says Seemant Chaturvedi, MD, a neurologist at University of Miami Miller School of Medicine. Women who do have high blood pressure or migraines or who smoke may, however, want to talk to their doctors about alternate birth control methods like IUDs or diaphragms, or different pill formulations.

Finally, familiarize yourself with the most common stroke symptoms. Although Marré and Hughes suffered serious headaches, “often, strokes do not hurt,” Dr. Cole explains, because the brain doesn’t have many pain-detecting nerve fibers. So what should women look out for? “If, all of a sudden, you can’t move, see, feel, speak, or walk, and you don’t have a really good reason for it, you ought to be thinking about a stroke,” Dr. Cole says. The face and arms are commonly affected, and speech and even texting can become difficult: One 25-year-old pregnant woman’s life may have been saved because her husband rushed home to take her to the hospital after receiving a series of confusing texts, including one that read, "every where thinging days nighing. Some is where! "

If symptoms like these ever hit, don’t delay. “The right thing to do is to call 911, and go to your closest emergency room,” says Aneesh Singhal, MD, a neurologist at Massachusetts General Hospital. (If you suspect you’re having a stroke but the doctors assume it’s something else, ask whether a neurologist can see you to rule out the possibility.)

In May 2013, less than a year after her first two strokes, Marré experienced another excruciating headache. This time she immediately went to the ER. It turned out she had, indeed, suffered a third stroke, but she had arrived at the hospital well within time to get the clot-busting drug, which doctors gave her in an IV. “The biggest thing that saved me from having more damage was understanding those symptoms,” she says.

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