Vascular risk factors
Managing blood pressure, lipids, glucose, and smoking — as clinicians would for anyone at elevated stroke risk. Targets are individualized in discussion with your care team.
Managing symptoms and vascular risk
Treatment & management
CADASIL care generally focuses on managing symptoms, addressing modifiable vascular risk factors, and applying established stroke-prevention principles where appropriate — coordinated with a CADASIL-aware clinical team.
What we know — and what we don't yet know
There is currently no treatment proven to reverse CADASIL or specifically stop its progression. Clinical care generally focuses on managing symptoms, addressing modifiable vascular risk factors, and applying established stroke-prevention principles where appropriate. Research is ongoing to determine which interventions may specifically influence outcomes in CADASIL. Individual medication and management decisions should be discussed with your own healthcare team.
Common domains of CADASIL care.
CADASIL care is typically multidisciplinary. The domains below describe areas commonly addressed in an individual care plan — not a universal prescription.
Migraine management
Targeted prevention and acute treatment, with appropriate caution around vasoactive options.
Cognition & mood
Routine screening, treatment of depression and apathy, cognitive rehabilitation, and selective use of pharmacotherapy.
Lifestyle & rehabilitation
Exercise, sleep, nutrition, social engagement, physical and occupational therapy where indicated.
Monitoring & surveillance
Periodic clinical and imaging follow-up — calibrated to the individual's age, severity, and goals.
Family & psychosocial
Genetic counselling, support for partners and caregivers, family planning, and peer connection.
Vascular risk factor management
Managing modifiable vascular risk factors is a standard part of care for anyone at elevated stroke risk, including people with CADASIL. Individual targets are set with your clinician.
Hypertension
Blood pressure management follows prevailing stroke-prevention guidelines, individualized by age, tolerance, and overall health. Targets are best set with your clinician.
Smoking
Smoking has been associated with worse imaging and clinical outcomes in reported CADASIL cohorts. Cessation is a widely recommended step; support is available through counselling, NRT, and pharmacotherapy.
Lipids
Statin therapy is reasonable in line with general stroke-prevention guidelines, particularly in patients with established cerebrovascular disease.
Diabetes & weight
Glycemic control and metabolic health are central. Encourage Mediterranean-style or DASH dietary patterns where feasible.
Migraine management in CADASIL
Migraine — particularly migraine with aura — is often the earliest and most disruptive symptom. Effective management improves quality of life and may reduce ER visits for confused stroke-mimic presentations.
Acute treatment
- Standard non-vasoactive analgesics (acetaminophen, NSAIDs) where tolerated
- Triptans are not absolutely contraindicated, but caution is warranted given their vasoconstrictive profile and the underlying small-vessel arteriopathy. Decisions should be individualized in consultation with a CADASIL-aware clinician.
- Ergot alkaloids are generally avoided.
- Newer CGRP-targeted acute therapies (gepants) may be a reasonable consideration in selected patients.
Preventive treatment
- Standard preventive options — including beta-blockers, candesartan, topiramate, and selected antidepressants — are typically appropriate.
- CGRP-targeted preventive therapies (monoclonal antibodies, gepants) may have a role; small-cohort data are reassuring but more evidence is needed.
- Lifestyle and trigger management are foundational.
Stroke vs. complex aura
Patients with CADASIL frequently present to the ER with prolonged or atypical aura that is difficult to distinguish from acute ischemia. Imaging, careful examination, and CADASIL-aware decision-making are essential. Communicate the diagnosis early to ER teams.
Antithrombotic decisions
Decisions around antiplatelet and anticoagulant therapy in CADASIL must balance ischemic stroke risk against the recognized risk of intracerebral hemorrhage from microbleeds and cerebral amyloid-like vasculopathy.
- Antiplatelet therapy (typically aspirin) is commonly used after an ischemic event in CADASIL, individualized to bleeding risk and microbleed burden.
- Dual antiplatelet therapy is generally avoided long-term given hemorrhage concerns.
- Anticoagulation is reserved for clear indications (e.g., atrial fibrillation), with careful weighing of bleeding risk.
- IV thrombolysis in the setting of acute stroke in a patient with known CADASIL is a nuanced decision — local stroke teams should coordinate with neurology and consider published case series.
Important nuance
Antithrombotic decisions in CADASIL should always be made by experienced clinicians, with imaging review and shared decision-making with the patient. Recommendations evolve as evidence accumulates.
Cognition, mood, and rehabilitation
Cognitive symptoms
When mood or apathy is present, treatment can help many people. SSRIs are commonly used; behavioural strategies play an important role for apathy in particular.
Cholinesterase inhibitors (e.g., donepezil) have been studied in CADASIL with mixed results — they did not demonstrate benefit on the primary global cognitive endpoint in the major randomized trial. Some clinicians consider individualized use for specific presentations. Discuss with a CADASIL-aware clinician.
Cognitive rehabilitation, structured cognitive activity, and management of sleep disorders may contribute to function.
Mood, apathy, anxiety
These are often under-recognized in CADASIL. Routine screening (e.g., PHQ-9 + apathy scale) at follow-up visits is a reasonable practice. Treatment options should be discussed with your clinician when symptoms are identified.
Rehabilitation
Standard stroke rehabilitation principles apply — physical therapy, occupational therapy, speech-language pathology, and gait training as needed. Falls prevention can become more important with advancing disease in some individuals.
What patients can do — every day.
Move
Regular aerobic activity, ideally 150 minutes/week, supports vascular and cognitive health.
Eat for the brain
Mediterranean / DASH-style eating patterns are well-aligned with cerebrovascular health.
Sleep
Sleep apnea screening matters. When identified, sleep disorders are typically treated — they can amplify vascular and cognitive risk.
Drink less
Limit alcohol; it is a recognized vascular risk factor and migraine trigger.
Stay engaged
Social, cognitive, and emotional engagement protect function. Isolation accelerates decline.
Plan ahead
Advance directives, financial planning, and legal arrangements are easier when made early — and bring peace of mind.
Drugs and procedures that warrant special caution.
- Cerebral angiography — historically associated with CADASIL-specific complications; modern non-invasive imaging (MRA, CTA) is generally preferred when feasible.
- IV thrombolytics in acute stroke — coordinate with stroke specialists and consider published case-series data.
- Triptans and ergots — discussed above.
- Hypotensive episodes — perioperative or intraoperative — should be avoided where possible.
- Hormonal contraception — discuss thrombotic and migraine risk individually with a CADASIL-aware clinician.