Continued Section 2014 Recommendation Description of Change from 2011 (Continued) As health professionals, we must ensure that progress in pre- venting stroke does not lead to complacency.We must acknowl- edge that several recommendations remain vague because of suboptimal clinical trial evidence or, even more concerning, may be out of date and therefore irrelevant. Diet and exercise are notoriously challenging to study with the same rigor as drugs or devices. It is easier to convince a patient to take a pill than to radically change his or her lifestyle. Nonetheless, we must expect the same standards of evidence for lifestyle interventions. Devices such as stents for carotid stenosis and occluders for PFO should be required to demonstrate favorable effects on patient-centered outcomes such as preventing stroke and not merely demonstrate favorable effects on surrogates such as expanding lumens or closing holes. The control groups of old that showed the benefits of CEA for asymptomatic stenosis would be seen as grossly undertreated medically by contemporary standards. It would be important to see if revas- cularization remains relevant in a modern context. Acknowledgments We thank medical librarians Ann Farrell at Mayo Clinic Rochester and Tara Brigham at Mayo Clinic Florida for assistance with a sys- tematic review of the medical literature. Migraine cont'd Closure of patent foramen ovale is not indicated for preventing stroke in patients with migraine (Class III; Level of Evidence B). New recommendation Drug abuse Referral to an appropriate therapeutic program is reasonable for patients who abuse drugs that have been associated with stroke, including cocaine, khat, and amphetamines (Class IIa; Level of Evidence C). 