Correspondence

Alcohol Consumption and the Risk of Stroke

N Engl J Med 2000; 342:1137-1138April 13, 2000

Article

To the Editor:

Berger and coworkers (Nov. 18 issue)1 report that light-to-moderate consumption of alcohol results in a slight reduction in the risk of stroke. It is difficult to believe that consuming only one drink per week could have a measurable effect on health, but assuming that this finding is correct, what are the public health implications?

There were 473 strokes of all types among 16,174 physicians who consumed one or more drinks per week, as compared with 206 strokes among the 5696 physicians who consumed less than one drink per week. If we apply the rates from the group that reported one or more drinks per week to the group that reported less than one drink per week, there might be a reduction of 39 strokes during an average follow-up period of about 12 years. This amounts to about three fewer strokes per year among more than 5000 persons.

The authors remind us that any increase in drinking is likely to be associated with an increase in heavy drinking. Therefore, the observed slight reduction in stroke-related disease would probably be offset by the predictable increases in alcohol-related morbidity and mortality. Despite the cautious tone of the article, the general public will consider this report, in a major scientific journal, as documentation of another example of the health benefits of alcohol consumption.

Albert B. Lowenfels, M.D.
New York Medical College, Valhalla, NY 10595

Patrick Maisonneuve, Eng.
European Institute of Oncology, 20141 Milan, Italy

1 References

1. 1

   Berger K, Ajani UA, Kase CS, et al. Light-to-moderate alcohol consumption and the risk of stroke among U.S. male physicians. N Engl J Med 1999;341:1557-1564
   Full Text | Web of Science | Medline

To the Editor:

Berger and colleagues describe an association between alcohol consumption and a reduced risk of stroke. They review several mechanisms by which alcohol may protect a person from stroke. Alternatively, the findings may represent, in part, uncontrolled confounding from a factor such as migraine. A confounding factor would need to be associated with a low consumption of alcohol and a high risk of stroke. The authors adjust for several base-line characteristics but not for migraine.

Alcohol consumption can trigger migraine headaches, and migraine is a risk factor for stroke, especially ischemic stroke.¹ Thus, on average, people with migraine may drink less alcohol and may be at greater risk for stroke than those without migraine, as noted in a previous report from the Physicians' Health Study.² Such an explanation would be consistent with the findings of the current study, including the L-shaped relation between alcohol consumption and stroke.

W.T. Longstreth, Jr., M.D., M.P.H.
Bruce M. Psaty, M.D., Ph.D.
University of Washington, Seattle, WA 98195

2 References

1. 1

   Raskin NH. Headache. 2nd ed. New York: Churchill Livingstone, 1988:35-98.
   

2. 2

   Buring JE, Hebert P, Romero J, et al. Migraine and subsequent risk of stroke in the Physicians' Health Study. Arch Neurol 1995;52:129-134
   Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Lowenfels and Maisonneuve point out that, in absolute numbers, the effect of light-to-moderate alcohol ingestion in reducing the risk of stroke was modest. This was reflected in the “cautious tone” of our article, since we indicated that this benefit should not be considered a reason for people to start drinking, but rather a reason for people to discuss this issue with their physicians and to address alcohol consumption in the context of their own health status and risk factors. On the other hand, the implication for public health is also that for the large number of people whose lifestyle includes the use of alcohol, its use may have a beneficial effect on cardiovascular and cerebrovascular health, provided that the amount consumed is light to moderate.

The possibility of uncontrolled confounding of the results by migraine is raised by Longstreth and Psaty. To address this issue, we repeated the analyses for total, ischemic, and hemorrhagic stroke and found that a history of migraine headache was a significant risk factor for total and ischemic stroke but not for hemorrhagic stroke. However, the relative risk of total stroke and of ischemic stroke for persons grouped according to increasing alcohol consumption (one, two to four, or five or six drinks per week or one or more drinks per day) remained virtually unchanged after additional adjustment for migraine (relative risk of total stroke, 0.78, 0.75, 0.83, and 0.80, respectively; relative risk of ischemic stroke, 0.72, 0.75, 0.81, and 0.80, respectively). Thus, these data indicate that uncontrolled confounding from migraine does not explain our findings.

Klaus Berger, M.D., M.P.H.
University of Muenster, 48129 Muenster, Germany

Carlos S. Kase, M.D.
Boston University, Boston, MA 02118

Umed A. Ajani, M.B., B.S., M.P.H.
Harvard University, Boston, MA 02215

Citing Articles (1)

Citing Articles

1. 1

   Gustavo W. Kuster, Andre L. Piraja da Silva, Camila H. Aquino, Luciene F. Ziviani, Renan B. Domingues. (2006) Frequency and Features of Delayed Alcohol-Induced Headache Among University Students. Headache: The Journal of Head and Face Pain 46:4, 688-691
   CrossRef