Ischaemic stroke may symptomatically manifest as migraine aura

Migraine aura is a common stroke mimic. We hypothesised that some patients with typical migraine aura symptoms might have embolic stroke detected as the precipitant. We identified fourteen patients who presented with symptoms consistent with a clinical diagnosis of migraine aura, but demonstrated subsequent evidence of acute infarction on magnetic resonance imaging (MRI). In all patients, migraine aura symptoms were not directly attributable to the vascular lesion on MRI. 50% of patients were classified as having an embolic stroke of undetermined source. Of these, a patent foramen ovale was identified in 4/5 of those who underwent transoesophageal echocardiogram, with large right-to-left shunt demonstrated in three. The results from our cohort suggest that migraine aura can be the presenting feature of acute ischaemic stroke, with local ischaemia presumably triggering a widely migrating cortical wave of spreading depolarization.