5 culprits behind rising cases of stroke in young women—are you overlooking new risk factors?
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More young people are having strokes. And as we started to research this, one thing that was shocking and disturbing to find was that women are having more strokes than men.
—Michelle Hu Leppert, MD
Picture this: A 27-year-old woman presents to the ED after experiencing 2 weeks of headache, neck pain, and dizziness. Her physical exam is unremarkable; she has no vascular risk factors, no recent trauma, and normal labs.
On deeper questioning, she reveals a daily habit: frequent use of a handheld massage gun on the neck. Imaging reveals vertebral artery dissection (VAD).[] This case, now reported in the literature, is part of a growing trend: early onset stroke, with VAD cited as one of the most common causes of stroke in patients under 45.[]
Young women have fewer classic risk factors for stroke, and despite a growing body of research and case reports, we still can't identify what exactly is behind rising cases. Ahead: 5 evidence-backed culprits potentially contributing to the trend.
1. Massage guns and ‘wellness’ devices
Handheld percussive devices—marketed as recovery tools—are increasingly implicated in cervical artery dissection (CeAD), one of the leading causes of ischemic stroke. []
Mechanism: Repetitive force may weaken the arterial wall or disrupt intimal integrity []
Clinical pattern: Headache, neck pain, and dizziness preceding neurologic deficit []
Population signal: Risks can be higher for women due to lower muscle mass compared with men, making their muscle tissue more vulnerable []
Even when causality is not definitive, the pattern is consistent enough that doctors are now advising blanket avoidance of using massage guns on the neck. []
“As a specialist in this field, my general mantra or thesis is to avoid any sort of neck manipulation or maneuvers—whether that means using a tool like a massage gun, having a chiropractor do some sort of manipulation, or having a masseuse do a deep muscle massage in your neck,” José M. Morales, MD, MSc, a vascular neurologist and neurointerventional surgeon at Pacific Neuroscience Institute, told MDLinx. []
2. Sexual strangulation (‘choking’)
If massage guns represent a consumer-device risk, sexual strangulation represents something more complex: a behavioral trend intersecting with vascular vulnerability.
Defined by external compression of neck structures, including carotid and vertebral arteries []
Associated with carotid artery dissection, stroke, and anoxic brain injury []
Some of the newer data is particularly striking:
Perhaps most provocative: Some public health groups now cite strangulation as a leading contributor to stroke risk in young women, with delayed events occurring days to months later. []
3. Migraines with aura
Migraine has a clearer vascular component than it's often given credit for. Migraine with aura is associated with roughly a twofold increased risk of ischemic stroke, with the strongest link seen in women under 45.[] The risk even appears in those without traditional cardiovascular risk factors.[] Mechanistically, migraine involves shifts in cerebral blood flow, endothelial dysfunction, and prothrombotic signaling—factors that can increase vulnerability to clot formation.[][]
4. Pregnancy
Pregnancy can raise stroke risk in ways that are easy to miss because many of the underlying changes are linked to pregnancy itself: It increases strain on the heart and blood vessels, increases blood clotting, and makes blood pressure issues more consequential.[][][]
Hypertension and preeclampsia are key drivers, while gestational diabetes and other complications increase both short- and long-term stroke risk.[]
For women with a prior stroke, the risk of recurrence during or soon after pregnancy is more than doubled.[]
5. Menopause
If menopause marks a hormonal transition, it also represents a vascular one, where declining estrogen intersects with rising stroke risk.
Defined by loss of estrogen’s protective effects on blood vessels, with increases in blood pressure, adverse lipid changes, and vascular stiffness[][]
Can promote a more atherogenic environment, accelerating vascular aging and stroke risk in postmenopausal years
Associated with earlier onset of cardiovascular and cerebrovascular disease when menopause occurs prematurely[][]
Some of the newer data is particularly notable:
Women who experience menopause before age 45—and especially before 40—have significantly higher stroke risk compared to those with typical timing[][]
Early menopause often clusters with conditions like endometriosis and premature ovarian insufficiency, suggesting shared underlying vascular vulnerability[]
Clinical guidance now recognizes premature menopause as a sex-specific stroke risk factor, alongside traditional risks like hypertension and diabetes[][]
Why young women?
There are several overlapping hypotheses:
Anatomical and connective tissue differences may increase susceptibility to arterial injury []
Higher exposure to certain behaviors (eg, sexual choking)
Under-recognition of risk because exposures are socially normalized or underreported
The result is a clinical blind spot: risk factors that don’t show up in standard intake templates.
Related: This simple daily habit can significantly lower stroke riskWhat this means in practice
Reframe 'trauma'. In young patients, especially women, trauma should include lifestyle and behavioral exposures involving the neck/spine.
Normalize the questions. A neutral, matter-of-fact approach is key: “We’re seeing more strokes related to pressure or strain on neck arteries—things like massage devices or even certain sexual practices. Does any of this apply to you?” That framing reduces stigma and increases disclosure.
Act earlier on subtle symptoms. Headache, neck pain, and dizziness in young patients, while not uncommon complaints, warrant a closer look.
Patient education is now preventive neurology. Clinicians are increasingly advised to counsel patients to avoid high-force neck manipulation, seek evaluation for persistent neck pain rather than self-treating, and understand that even brief neck compression can carry vascular risk—especially important during life transitions like pregnancy or menopause.