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Migraine with visual aura, incident AF, and stroke risk

Migraine with aura is an undisputed risk factor for ischemic stroke.1 Several mechanisms may mediate this risk, including genetic predisposition (e.g., NOTCH3, CACNA1A, SCN1A, ATP1A2); hypercoagulability (e.g., antiphospholipid antibodies, elevated von Willebrand factor and fibrinogen); hyperviscosity (polycythemia); increased platelet aggregability; hyperhomocysteinemia; elevated estrogens; paradoxical embolism from patent foramen ovale; and dissection of carotid, vertebral, or cerebral arteries.2,3 Recently, a study based on data from the Atherosclerosis Risk in Community (ARIC) study found a specific association between migraine with visual aura (MVA) and elevated risk of cardioembolic ischemic stroke.4 That study did not obtain data on patent foramen ovale, thus it remains unclear whether patent foramen ovale prevalence drives the association. Instead, it was hypothesized that shared autonomic and inflammatory mechanisms of migraine and atrial fibrillation may have mediated the association.5