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.