What is the Source of Migraines After Left-Sided Ablation Procedures?
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EP LAB DIGEST. 2026;26(2):6.
Bradley P Knight, MD, FACC, FHRS
Dear Readers,
It is not uncommon for patients to complain about symptoms of a migraine-like visual aura within a few hours after undergoing a catheter ablation procedure for atrial fibrillation (AF). Although these symptoms are usually transient, any neurological concerns after a left-sided ablation procedure raises the concern for an embolic neurologic event.
For years, there has been suspicion that, much like a patent foramen ovale, transseptal catheterization itself and the residual iatrogenic atrial septal defect from the procedure could cause migraines. This could be either from paradoxical emboli or right-to-left shunting of some chemical that bypasses the lungs unfiltered. However, there is little convincing evidence that such defects cause migraine symptoms or that closure of the defect prevents recurrence.
It is also well-known that catheter ablation procedures for AF can result in a stroke or transient ischemic attack by causing cerebral embolism. Sources of emboli to the brain include preexisting left atrial appendage thrombus, endothelial disruption, thrombus formation on the ablation catheter or sheath, heat-related char formation, or air from saline irrigation of the delivery sheath or ablation tool. Careful saline flush management, minimizing left-sided catheter and sheath exchanges, continuous ACT-guided therapeutic heparin anticoagulation, and performance of the procedure on uninterrupted oral anticoagulation have been shown to reduce the rate of major embolic complications related to AF ablation.
So, when a patient complains about visual aura after an AF ablation procedure, is this just a simple migraine or is it an actual stroke-like event? Is it just related to the anesthesia or periprocedural fasting and caffeine withdrawal, or something more concerning? To address this question, the investigators from the Transseptal Versus Retrograde Aortic Ventricular Entry to Reduce Systemic Emboli trial analyzed their data related to postprocedural migraines.1 In this study, patients undergoing catheter ablation for ventricular arrhythmias were randomized to ventricular access via transseptal puncture vs a retrograde aortic approach. Each patient underwent brain magnetic resonance imaging the day after the procedure and completed a migraine assessment at 1 month. They found no differences in postablation visual auras between transseptal (16%) and retrograde aortic approaches (14%; P=.78). Importantly, “more participants with acute brain emboli in the occipital or parietal lobes experienced migraine-related visual auras (38% vs 11%; P<.01). After multivariable adjustment, the presence of acute brain emboli was associated with 12-fold greater odds of visual auras.”1
This study by Elias and colleagues clearly demonstrates that visual auras can occur in up to 15% of patients after a left-sided ablation, and that at least some patients who have a migraine-related visual aura after an AF ablation procedure have had acute brain emboli occipital or parietal lobes as the source of their symptoms. It is not clear if these patients should be managed differently than patients who do not have neurological symptoms after an AF ablation, but it sheds some light on these symptoms, further emphasizes the need to minimize the risk of any brain embolism associated with left-sided cardiac procedures, and highlights the fact that some cases of silent cerebral emboli might appear silent but are quite visible to the patient.
Disclosures: Dr Knight has served as a paid consultant to Medtronic and was an investigator in the PULSED AF trial. He has served as a consultant, speaker, investigator, and/or has received EP fellowship grant support from Abbott, AltaThera, AtriCure, Baylis Medical, Biosense Webster, Biotronik, Boston Scientific, CVRx, Philips, and Sanofi; he has no equity or ownership in any of these companies. Dr Knight reports payment or honoraria from Convatec for a lecture.
