Reader Response: Microembolism and Other Links Between Migraine and Stroke: Clinical and Pathophysiologic Update

We read with great interest the review by Sacco et al.¹ and generally agree with their findings. However, we would like to outline some limitations. First, the clinical description of symptoms of stroke compared with the habitual migraine aura is limited to 2 small series: Olesen et al.² reported 5 patients with previous MA and ischemic stroke, and Wolf et al.³ took the symptoms of 11 patients solely from the charts. Therefore, we believe that more emphasis should be put on the lack of data on clinical features of stroke in patients with known migraine with aura.

Second, a change of aura symptoms might occur without it necessarily being a stroke, an issue of enormous clinical relevance that has not been covered by the review. Clinical features that help differentiate a nonstereotypical aura from an ischemic stroke are still unclear. This is of particular importance because even patients without a history of migraine with aura often report migraine-like symptoms during ischemic stroke.⁴ Third, the complex association between atrial fibrillation and migraine has been a little oversimplified not covering issues, such as hypercoagulability, antithrombotics as migraine prevention therapy, and others.⁵