Response to Letter by Di Legge et al
Di Legge and colleagues suggest that modifying conventional vascular risk factors (RF) as well as lifestyle habits may influence migraine outcome, and the lack of control on this variable may have interfered with the effect of patent foramen ovale closure in our study. In support of this contention they quote the higher load of vascular RF found in controls.
The reported increased frequency of vascular RF in migraineurs with aura1 is intriguing and somewhat misleading inasmuch as some of them such as hypertension, use of contraceptives and smoking might themselves be triggers of migraine attacks in migraineurs with aura and hence increase the likelihood of self-reported migraine. Moreover, although theoretically appealing, to the best of our knowledge there is no evidence supporting the notion that modifying vascular risk factors may alter migraine course to an extent comparable with that found in our patients, except, perhaps the abstention from recognized trigger foodstuff. Finally, the quoted higher frequency of risk factors in controls in our study applies only to patients who had had a stroke, because between controls and patients subjected to closure but with no previous history of stroke there was no difference whatsoever. On the other hand, there is no a priori reason to believe that patients in the control group were treated differently with respect to the interventional cohort in terms of behavioral counseling or therapeutic monitoring.
Therefore, although admitting that in general terms migraine treatment should be comprehensive, including counseling for a healthy behavior, we do not think that the lack of control on this aspect of treatment have played any significant role in explaining our results.