Symptoms & progression
CADASIL symptoms usually appear in this order: migraine with aura (often starting in the 20s–30s), recurrent strokes and TIAs (40s–50s), mood changes and apathy throughout, and progressive cognitive decline that can reach dementia by around 65. Onset and severity vary widely, even within the same family.
There's a rough pattern, but no two people — even in the same family — follow it exactly. Migraines with aura often come first, sometimes years before anything else. Strokes and mini-strokes tend to arrive in mid-life. Depression and apathy can show up at any point and are part of the disease, not a personal failing. Cognitive changes — trouble planning, focusing, remembering — usually come later. Fatigue is one of the most common and least-discussed symptoms.
- Migraine with aura: ~30–40% of patients; average onset ~30. Often the first symptom.
- Ischemic strokes / TIAs: the most common presenting sign; average onset ~49 (range ~20–70).
- Mood: depression, irritability, and apathy (a core feature that can occur independent of depression).
- Cognitive decline: deficits in executive function, attention, and processing speed, often reaching dementia by ~65.
- Fatigue: consistently ranks among the most bothersome patient-reported symptoms.
Common questions
- What is usually the first sign of CADASIL?
- Often migraine with aura, sometimes years before strokes.
- Does CADASIL cause dementia?
- It can — progressive vascular cognitive impairment is common in later stages.
- Is depression part of CADASIL?
- Yes — mood changes and apathy are core features, and treatable.