Reader response: Migraine with visual aura is a risk factor for incident atrial fibrillation: A cohort study

I read with interest the article by Sen et al.¹ The investigators believe that migraine with aura (MwA) and migraine without aura (MwoA) are distinct clinical entities. Neuropharmacologically, both beta-blockers and tricyclic antidepressants are equally effective in the prevention of both variants. This study¹ does not distinguish between variants of migrainous visual aura.² Only the migrainous visual field loss without scintillation can be conceived of as being of ischemic origin. The pathognomonic scintillating scotoma was not seen in any patient.¹ Retrospective questionnaire responses for migrainous visual aura are highly subjective.

Recurrent stereotyped MwA-headache attacks of atrial fibrillation (AF)-related thromboembolism require the presumed passage of vascular-occluding substance(s) into the same cranial vascular territory, predictably or unpredictably, over decades—a highly unlikely to impossible clinical scenario.³ AF begins in the right atrium. The pulmonary circulation cannot remain indefinitely spared in patients with MwA-AF. There is also no difference in autonomic dysfunction between patients with MwA and patients with MwoA, as speculated.¹

Meta-analysis obtains bizarre associations and has introduced a façade of mathematical acceptability that draws the clinician away from reality.⁴ The linkage of AF-related presumed thromboembolism to patients with MwA,¹ despite lack of commonsense and logic in closure of the patent foramen ovale to prevent migraine attacks,³ appears to be misplaced.