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?