2006 Heart-Brain summit proceedings
Patent foramen ovale
and migraine
ARTICLE INTRODUCTION
Migraine is a complex disorder in which many psychological, environmental, biochemical, neurophysiologic, and genetic factors may play a role to trigger attacks. Although its course is usually benign and it tends to abate with age, migraine has long been suspected as a risk factor for stroke. A number of case-control studies and a recent meta-analysis have demonstrated that the relative risk of stroke is as follows in the following groups of migraineurs compared with nonmigraineurs:
- 1.83 in people with migraine without aura
- 2.27 in people with migraine with aura
- 8.27 in female migraineurs who smoke and take oral contraceptives.
Furthermore, migraineurs are more likely to exhibit silent ischemic lesions on magnetic resonance imaging.
CITATIONS
- Welch KMA.
Contemporary concepts of migraine pathogenesis. Neurology 2003; 61(Suppl 4): S2–S8.
http://www.ncbi.nlm.nih.gov/pubmed/14581652 - Silberstein SD.
Migraine. Lancet 2004; 363:381–391.
http://www.ncbi.nlm.nih.gov/pubmed/15070571 - Chang CL, Donaghy M, Poulter N.
Migraine and stroke in young women: case-control study. The World Health Organisation Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. BMJ 1999; 318:13–18.
http://www.ncbi.nlm.nih.gov/pubmed/9872876 - Carolei A, Marini C, de Matteis G.
History of migraine and risk of cerebral ischaemia in young adults. Lancet 1996; 347:1503–1506.
http://www.ncbi.nlm.nih.gov/pubmed/8684100 - Tzourio C, Tehindrazanarivelo A, Iglesias S, et al.
Case-control study of migraine and risk of ischaemic stroke in young women. BMJ 1995; 310:830–833.
http://www.ncbi.nlm.nih.gov/pubmed/7711619 - Etminan M, Takkouche B, Isorna FC, Samii A.
Risk of ischaemic stroke in people with migraine: systematic review and meta-analysis of observational studies. BMJ 2005; 330:63–66.
http://www.ncbi.nlm.nih.gov/pubmed/15596418 - Kruit MC, Van Buchem MA, Hofman PA, et al.
Migraine as a risk factor for subclinical brain lesions. JAMA 2004; 291:427–434.
http://www.ncbi.nlm.nih.gov/pubmed/14747499 - Del Sette M, Angeli S, Leandri M, et al.
Migraine with aura and right-to-left shunt on transcranial Doppler: a case-control study. Cerebrovasc Dis 1998; 8:327–330.
http://www.ncbi.nlm.nih.gov/pubmed/9774749 - Anzola GP, Magoni M, Guindani M, Rozzini L, Dalla Volta G.
Potential source of cerebral embolism in migraine with aura: a transcranial Doppler study. Neurology 1999; 52:1622–1625.
http://www.ncbi.nlm.nih.gov/pubmed/10331688 - Domitrz I, Mieszkowshi J, Kwiecinski H.
Prevalence of patent foramen ovale in patients with migraine. Neurol Neurochir Pol 2004; 38:89–92.
http://www.ncbi.nlm.nih.gov/pubmed/15307600 - Lamy C, Giannesini C, Zuber M, et al, for the Patent Foramen
Ovale and Atrial Septal Aneurysm Study Group.
Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale. The PFO-ASA Study. Stroke 2002; 33:706–711.
http://www.ncbi.nlm.nih.gov/pubmed/11872892 - Sztajzel R, Genoud D, Roth S, Mermillod B, Le Floch-Rohr J.
Patent foramen ovale, a possible cause of symptomatic migraine: a study of 74 patients with acute ischemic stroke. Cerebrovasc Dis 2002; 13:102–106.
http://www.ncbi.nlm.nih.gov/pubmed/11867883 - Wilmshurst P, Nightingale S.
The role of cardiac and pulmonary pathology in migraine: a hypothesis. Headache 2006; 46:429–434.
http://www.ncbi.nlm.nih.gov/pubmed/16618259
PFO AND MIGRAINE
TABLE 2
Summary of results of nonrandomized trials on the effects of patent foramen ovale closure on migraine*
No. Mean follow-up Patients with Patients with
Author Year Type of study of pts (months) resolution (%) improvement (%)
Wilmshurst et al18 2000 Retrospective 21 17 48 38
Morandi et al19 2003 Prospective 17 12 29 59
Schwerzmann et al20 2004 Retrospective 47 24 Not reported 83
Post et al21 2004 Retrospective 26 6 84 Not reported
Azarbal et al22 2005 Retrospective 37 3 60 40
Reisman et al23 2005 Retrospective 50 12 56 14
Giardini et al24 2006 Retrospective 35 20 83 8
Overall results of retrospective trials 233 13 60 40
Anzola et al25 2006 Prospective case-control 50 12 38 48 * The only case-control study (reference 25) is contrasted with earlier reports. - Schwedt TJ, Dodick DW.
Patent foramen ovale and migraine— bringing closure to the subject. Headache 2006; 46:663–671.
http://www.ncbi.nlm.nih.gov/pubmed/16643562 - Anzola GP, Morandi E, Casilli F, Onorato E.
Different degrees of right-to-left shunting predict migraine and stroke. Data from 420 patients. Neurology 2006; 66:765–767.
http://www.ncbi.nlm.nih.gov/pubmed/16534123 - Beda RD, Gill EA Jr.
Patent foramen ovale: does it play a role in the pathophysiology of migraine headache? Cardiol Clin 2005; 23:91–96.
http://www.ncbi.nlm.nih.gov/pubmed/15676272 - Wilmshurst PT, Pearson MJ, Nightingale S, Walsh KP, Morrison WL.
Inheritance of persistent foramen ovale and atrial septal defects and the relation to familial migraine with aura. Heart 2004; 90:1315–1320.
http://www.ncbi.nlm.nih.gov/pubmed/15486131 - Wilmshurst PT, Nightingale S, Walsh KP, Morrison WL.
Effect on migraine of closure of cardiac right-to-left shunts to prevent recurrence of decompression illness or stroke or for haemodynamic reasons. Lancet 2000; 356:1648–1651.
http://www.ncbi.nlm.nih.gov/pubmed/11089825 - Morandi E, Anzola GP, Angeli S, Melzi G, Onorato E.
Transcatheter closure of patent foramen ovale: a new migraine treatment? J Intervent Cardiol 2003; 16:39–42.
http://www.ncbi.nlm.nih.gov/pubmed/12664816 - Schwerzmann M, Wiher S, Nedeltchev K, et al.
Percutaneous closure of patent foramen ovale reduces the frequency of migraine attacks. Neurology 2004; 62:1399–1401.
http://www.ncbi.nlm.nih.gov/pubmed/15111681 - Post MC, Thijs V, Herroelen L, Budts WI.
Closure of a patent foramen ovale is associated with a decrease in prevalence of migraine. Neurology 2004; 62:1439–1440.
http://www.ncbi.nlm.nih.gov/pubmed/15111695 - Azarbal B, Tobis J, Suh W, Chan V, Dao C, Gaster R.
Association of interatrial shunts and migraine headaches Impact of transcatheter closure J Am Coll Cardiol 2005; 45:489–492.
http://www.ncbi.nlm.nih.gov/pubmed/15708691 - Reisman M, Christofferson RD, Jesurum J, et al.
Migraine headache relief after transcatheter closure of patent foramen ovale. J Am Coll Cardiol 2005; 45:493–495.
http://www.ncbi.nlm.nih.gov/pubmed/15708692 - Giardini A, Donti A, Formigari R, et al.
Transcatheter patent foramen ovale closure mitigates aura migraine headaches abolishing spontaneous right-to-left shunting. Am Heart J 2006; 151:922.e1–922.e5.
http://www.ncbi.nlm.nih.gov/pubmed/16569564 - Anzola G, Frisoni GB, Morandi E, Casilli F, Onorato E.
Shuntassociated migraine responds favorably to atrial septal repair: a casecontrol study. Stroke 2006; 37:430–434.
http://www.ncbi.nlm.nih.gov/pubmed/16373630 - Dowson A.
Migraine Intervention with STARFlex Technology (MIST) Trial. Slides presented at: American College of Cardiology Scientific Session 2006. Available at: www.clinicaltrialresults.org. - Wilmshurst PT, Nightingale S, Walsh KP, Morrison WL.
Clopidogrel reduces migraine with aura after transcatheter closure of persistent foramen ovale and atrial septal defects. Heart 2005; 91:1173–1175.
http://www.ncbi.nlm.nih.gov/pubmed/16103551 - Del Sette M, Dinia L, Finocchi C, et al.
SAM (Shunt Associated Migraine) study: studio multicentrico osservazionale su emicrania e shunt destro-sinistro al TCD [abstract]. Presented at: Italian Stroke Forum 2005. Available at:
http://www.strokeforum.org/Stroke2005/Abstracts.htm. - Khairy P, O’Donnell C, Landzberg MJ.
Transcatheter closure versus medical therapy of patent foramen ovale and presumed paradoxical thromboemboli. A systematic review. Ann Intern Med 2003; 139:753–760.
http://www.ncbi.nlm.nih.gov/pubmed/14597460 - Anzola GP, Morandi E, Casilli F, Onorato E.
Does transcatheter closure really “shut the door”?: a prospective study with transcranial doppler. Stroke 2004; 35:2140–2144.
http://www.ncbi.nlm.nih.gov/pubmed/15284445