Ensuring complete closure of the PFO would eliminate those processes. Ben-Assa described the association between PFO and migraine as complex. Although the randomized trials failed to show a significant benefit on their primary endpoints, there were positive signs. He and his colleagues tried to tease some of that nuance out in the current study. We should strive for complete closure and if someone has aura we can tell them that the literature suggests that they will have higher likelihood to improve.
Eyal Ben-Assa. During a median follow-up of 3. Only four patients 3. Patients without residual shunt were more likely to have an improvement in migraine burden.
She said she was not very surprised to see that patients with aura were more likely to have a complete elimination of migraine symptoms after closure because she has adhered to the belief that a substantial proportion of migraine with aura is triggered by microemboli or vasoactive substances traveling to the brain. More surprising, Tietjen said, was the large reduction in migraine burden in patients without aura and the effect of residual shunt.
Patients with mild shunt still had a reduction in migraine symptoms, but not as much as when it was absent. The study investigators called for future trials of PFO closure in migraineurs that incorporate these findings and aim to identify the specific subsets of patients who will benefit.
What that suggests to me is that it may not be just microemboli. It points to the presence of other vasoactive substances or hypoxia in the shunted blood playing a role. Gretchen Tietjen. There are still many questions that should be addressed in the migraine population in collaboration with neurologists.
Transesophageal echocardiography or at least intracardiac echography should be used to guide the procedure. He got his start in journalism at …. Effect of residual interatrial shunt on migraine burden after transcatheter closure of patent foramen ovale. J Am Coll Cardiol Intv. Multiple clinical trials have been conducted to determine if closing a PFO a procedure that can be done on an outpatient basis by a cardiologist is helpful for migraine.
None of the studies met its primary endpoint, meaning that none showed the PFO closure was significantly effective in reducing migraine in all migraine patients. Therefore, based on the evidence that we have to date, we know there is an association between PFO and migraine, but it is important to note that an association does not indicate causation. We are in an interesting situation, where despite the fact that the clinical trials of PFO closure for migraine have been negative, there may be a subgroup of patients for whom PFO closure may be effective.
Further studies with carefully selected patients may be warranted. An interesting possibility is that PFO could be responsible for increased risk of stroke in migraine patients.
In patients who have blood clots or air bubbles in their veins, PFO can allow the clots or bubbles to cross over to the arteries and travel directly to the brain. We just recently published a paper in Stroke that describes a study we conducted with UCLA stroke patients.
In collaboration with stroke neurologists and cardiologists at UCLA, we examined stroke patients had UCLA who had no apparent reason for having a stroke; i. We found that, of those patients, a striking percentage had PFO.
Another striking percentage had migraine. The clinical trials do not give us evidence to support PFO closures in migraine patients, and yet the relationship between PFO, migraine, and stroke remains a fascinating issue. I do not want in any way to advocate that we should be performing PFO closure in most patients with migraine. But I believe that further research is warranted to try to better understand a potential role for PFO in migraine. Andrew Charles, MD, FAHS, is a member of the American Headache Society, a professional society for doctors and other health care workers who specialize in studying and treating headache and migraine.
The American Headache Society founded the American Migraine Foundation AMF to provide access to information and resources for individuals living with migraine, as well as their loved ones. AMF is a non-profit organization dedicated to the advancement of research and awareness surrounding migraine. You are now being redirected to the AMF website where patients can learn more, find help and get connected. Sub-group analyses were performed looking at age, gender, history of head trauma, mood disorder, palpitations, snoring, steroid use, migraine with aura, and Migraine Disability Assessment and Beck Depression Inventory scores.
Safety outcomes were reported for procedural complications for all subjects who received devices both randomized subjects as well subjects from PREMIUM who had PFO closed after blinding was removed. This analysis was performed "as-treated. Results No significant differences were observed in patient characteristics in the 2 treatment arms.
Mean reduction in monthly migraine days was 3. Mean reduction in monthly migraine attacks was Migraineurs with aura had significant reduction in migraine days and headache cessation 3. There were 4 device-related complications: 1 fatigue, 2 with non-sustained atrial fibrillation, and 1 with syncope. Limitations The 2 trials had different primary endpoints, so there is inherent bias in interpreting their results together.
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