Impact of AF Ablation on Trajectory of Migraine | Journal Scan

Study Questions:

Does catheter ablation (CA) of atrial fibrillation and periprocedural anticoagulation regimen affect the trajectory of migraine in patients with or without migraine history?

Methods:

Forty patients with and 85 without migraine history undergoing atrial fibrillation (AF) ablation were enrolled. Migraine status was evaluated. Diffusion magnetic resonance imaging (dMRI) of the brain was performed for all at pre- and 24-hour post-procedure.

Results:

CA was performed with (n = 88, 70%) or without (n = 37, 30%) continuous warfarin treatment. Fifty-four patients had subtherapeutic international normalized ratio (INR) on the procedure day. At a mean of 17 months, among patients with a history of migraines, 63 reported no migraine, 25% reported <1 migraine/month, and 8% had 2-3 monthly symptoms. Average intensity of pain decreased post-ablation. There were new cerebral infarcts post-ablation on dMRI in 9.6% of patients, all but one of which occurred in patients subtherapeutic on or off warfarin.

Conclusions:

The authors concluded that migraine symptoms improve after AF catheter ablation. New migraine and aggravation of pre-existent migraine had subtherapeutic INR during the procedure and new cerebral infarcts.

Perspective:

An association between patent foramen ovale (PFO) and migraine headache has been observed previously in several studies, although a randomized study to close PFO in patients with migraines was negative (Circulation 2008;117:1397-1404). Mohanty et al. add a new twist to the story by suggesting that AF ablation may improve migraines. Wow! During AF ablation, a transseptal puncture with a physiology similar to atrial septal defect/PFO is invariably performed, although most puncture sites close with time. What could be the causal relationship responsible for the improvement in migraine post-AF ablation? Changes in autonomic innervation of the heart? Interestingly, four patients experiencing either increased migraine severity or new-onset migraine had subtherapeutic INR on the procedure day (some patients were instructed to stop warfarin and were bridged with enoxaparin). The same patients had newly detected post-procedure infarcts on dMRI. Of note, patients with subtherapeutic INRs were bridged with enoxaparin (1 mg/kg bid pre-procedure, and 0.5 mg/kg post-procedure as long as INR was subtherapeutic). This suggests that the discontinuation of warfarin with bridging may be associated with an increase in silent cerebral infarcts. The question arises: Are patients taking target-specific anticoagulants at higher risk of migraines and dMRI-detected cerebral infarcts post-ablation than warfarin patients?

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Noninvasive Imaging, Prevention, Anticoagulation Management and Atrial Fibrillation, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Prevention, Magnetic Resonance Imaging

Keywords: Atrial Fibrillation, Anticoagulants, Catheter Ablation, Cerebral Infarction, Diffusion Magnetic Resonance Imaging, International Normalized Ratio, Migraine Disorders, Acute Pain, Warfarin, Secondary Prevention, Punctures, Enoxaparin, Foramen Ovale, Patent


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