Impact of transcatheter closure of patent foramen ovale in the evolution of migraine and role of residual shunt

Patent Foramen Ovale Percutaneous Closure: Evolution and Ongoing Challenges

Patent foramen ovale (PFO) concerns nearly a quarter of the general population and incidence may reach up to 50% in patients with cryptogenic stroke. Recent randomized clinical trials confirmed that percutaneous closure of PFO-related stroke reduces the risk of embolic event recurrence. PFO also comes into play in other pathogenic conditions, such as migraine, decompression sickness or platypnea-orthodeoxia syndrome, where the heterogeneity of patients is high and evidence for closure is less well-documented. In this review, we describe the current indications for PFO percutaneous closure and the remaining challenges, and try to provide future directions regarding the technique and its indications.

Efficacy and safety of transesophageal ultrasound-guided patent foramen ovale closure for migraine in adolescents

Objective

This retrospective analysis aims to assess the efficacy of transesophageal ultrasound-guided patent foramen ovale (PFO) closure in treating migraine in adolescents and compare the therapeutic outcomes of PFO closure for migraine with and without aura.

Methods

We conducted a retrospective analysis of 86 cases of adolescents (12-20 years old) who underwent PFO closure for migraine at our institution over the past 3 years. The efficacy was evaluated using the visual analogue scale (VAS), headache impact test (HIT)-6, and pediatric migraine disability assessment (PedMIDAS) scores, as well as by assessing the monthly frequency of migraine attacks, duration of each attack, and overall migraine burden. The patients were divided into two groups: an aura group (55 cases) and a non-aura group (31 cases) to investigate difference in therapeutic efficacy between the groups. The effect of residual shunt on migraine burden was assessed.

Results

Among the 86 patients, 46 (54%) experienced complete remission of migraine, while 71 (83%) achieved a >50% reduction in migraine burden during the one-year follow-up period. Patients in the aura group showed more significant improvements in VAS, HIT-6, and PedMIDAS scores, as well as in monthly migraine attack frequency, duration of each attack, and overall migraine burden, than patients in the non-aura group. Moreover, patients with residual shunt did not exhibit statistically significant differences in therapeutic efficacy compared to patients with complete closure.

Conclusion

PFO closure can effectively alleviate migraine symptoms in adolescents with migraine with concomitant PFO. The therapeutic efficacy is particularly pronounced for migraine with aura. Furthermore, minor levels of residual shunt have no effect on the improvement in migraine symptoms.

Association of migraine with patent foramen ovale closure: A systematic review and meta-analysis

Background

Method

Result

Conclusion

European position paper on the management of patients with patent foramen ovale. Part II - Decompression sickness, migraine, arterial deoxygenation syndromes and select high-risk clinical conditions

Patent foramen ovale (PFO) is implicated in the pathogenesis of a number of medical conditions but to date only one official position paper related to left circulation thromboembolism has been published. This interdisciplinary paper, prepared with the involvement of eight European scientific societies, reviews the available evidence and proposes a rationale for decision making for other PFO-related clinical conditions. In order to guarantee a strict evidence-based process, we used a modified grading of recommendations, assessment, development, and evaluation (GRADE) methodology. A critical qualitative and quantitative evaluation of diagnostic and therapeutic procedures was performed, including assessment of the risk/benefit ratio. The level of evidence and the strength of the position statements were weighed and graded according to predefined scales. Despite being based on limited and observational or low-certainty randomised data, a number of position statements were made to frame PFO management in different clinical settings, along with suggestions for new research avenues. This interdisciplinary position paper, recognising the low or very low certainty of existing evidence, provides the first approach to several PFO-related clinical scenarios beyond left circulation thromboembolism and strongly stresses the need for fresh high-quality evidence on these topics.

The Efficacy of Percutaneous Patent Foramen Ovale Closure on Migraine: a Meta-Analysis of Randomized Controlled Trials and Observational Studies

Objectives

Whether patent foramen ovale (PFO) closure is effective on migraine is controversial. This article was aimed at assessing the efficacy of PFO closure on migraine based on randomized controlled trials (RCTs) and observational studies.

Methods

We searched PubMed, Embase, and Cochrane databases up to October 2020 evaluating PFO closure versus control in patients with migraine, then conducted a meta-analysis of all RCTs and observational studies, respectively. The main outcomes were (1) respond rate: complete cessation of migraine; (2) reduction in the frequency of migraine attacks per month; and (3) reduction in migraine days per month.

Results

Seven studies (3 RCTs and 4 observational studies), containing 887 migraine patients, were identified. (1) The respond rate of PFO closure on migraine was significantly higher than control group both in RCT subgroup and observational studies subgroup (OR 3.86, 95% CI 1.35-11.04, P = 0.01 in RCTs; OR 8.28, 95% CI 2.31-29.67, P = 0.001 in observational studies). (2) Reduction in frequency of migraine attacks was higher in PFO closure group compared with control group in the RCT subgroup analysis (mean difference (MD) = 0.57, 95% CI 0.23-0.90, P = 0.0009). (3) Reduction in migraine days was also higher in PFO closure group compared with control group in the RCT subgroup analysis (MD = 1.33, 95% CI 0.35-2.31, P = 0.008).

Conclusions

PFO closure might be suitable for migraine patients, especially for migraine with aura, by cessation of migraine headaches or reducing migraine attacks and migraine days.

The Correlation Between Migraine and Patent Foramen Ovale

Background: Migraine is a widespread neurological disorder. The patent foramen ovale (PFO) is a remnant of the fetal circulation. Multiple studies suggest that migraine is more prevalent in subjects with PFO and vice versa. It is unclear if there is a causal relationship or simply a co-existence of these two conditions. Furthermore, the treatment of migraine with percutaneous closure PFO remains controversial.

Methods: We reviewed studies pertaining to the relationship between PFO and migraine as well as the effects of treatments on migraine attacks.

Results: We briefly summarized potential pathophysiological mechanisms of migraine, and elaborated on migraine type, frequency, and clinical symptoms of migraine with PFO and the clinical features of PFO with migraine. We also addressed the effects of PFO closure on migraine attacks.

Conclusion: The evidence supports a “dose-response” relationship between migraine and PFO although more work needs to be done in terms of patient selection as well as the inclusion of an antiplatelet control group for PFO closure interventions to uncover possible beneficial results in clinical trials.

Migraine and risk of stroke

Migraine and stroke are two common and heterogeneous neurovascular disorders responsible for a significant burden for those affected and a great economic cost for the society. There is growing evidence that migraine increases the overall risk of cerebrovascular diseases. In this review, based on available literature through a PubMed search, we found that ischaemic stroke in people with migraine is strongly associated with migraine with aura, young age, female sex, use of oral contraceptives and smoking habits. The risk of transient ischaemic attack also seems to be increased in people with migraine, although this issue has not been extensively investigated. Although migraine appears to be associated with haemorrhagic stroke, the migraine aura status has a small influence on this relationship. Neuroimaging studies have revealed a higher prevalence of asymptomatic structural brain lesions in people with migraine. They are also more likely to have unfavourable vascular risk factors; however, the increased risk of stroke seems to be more apparent among people with migraine without traditional risk factors. The mechanism behind the migraine-stroke association is unknown. In light of the higher risk of stroke in people with migraine with aura, it is important to identify and modify any vascular risk factor. There is currently no direct evidence to support that a migraine prophylactic treatment can reduce future stroke in people with migraine.

PFO and Migraine: Is There a Role for Closure?

Observational studies suggest that closure of a patent foramen ovale for other indications may reduce or even eliminate migraine attacks, particularly migraine with aura. The first randomized clinical trial of patent foramen ovale (PFO) closure for prevention of migraine, the MIST trial, showed negative results. The results of the other two completed studies in this area have recently been published in the last year. PRIMA and PREMIUM were also both negative for their primary endpoints. The PREMIUM trial did show a reduction in headache days in the migraine with aura subgroup but the final results of this subset analysis have not been published. There may be an as yet undetermined subgroup of patients with migraine who would benefit from closure, but slow recruitment has been a barrier to further study. Several potentially life-threatening procedure-related adverse events occurred in the clinical trials. At this time, we recommend against offering PFO closure as a preventive treatment for migraine. Based on available observational data, patients for whom PFO closure is indicated for other reasons may see some improvement in their migraines.

Clinical outcomes of secondary prevention strategies for young patients with cryptogenic stroke and patent foramen ovale

Background The aim of this study was to compare the immediate and long-term clinical outcomes of medical therapy and percutaneous patent foramen ovale (PFO) closure as secondary prevention strategies in patients younger than 55 years of age presenting with cryptogenic stroke and PFO. Methods Between January 2006 and April 2015, all patients with the diagnosis of cryptogenic stroke and PFO were analysed and prospectively followed. Stroke was confirmed in 159 out of 309 patients (51%). In the remaining cases, other neurological conditions were found and therefore excluded from further analysis. Patients received PFO closure or medical therapy on the basis of a pre-specified algorithm. Primary outcome was the assessment of recurrent ischaemic events at follow-up. Results Percutaneous PFO closure was performed in 77 patients (48%) and 82 (52%) were treated medically. Mean follow-up was 51.6 ± 34.8 months. Two ischaemic strokes occurred in the medical group only (2.4% vs 0%; P = 0.16) and no complications related to the invasive procedure were observed. Conclusions The diagnosis of stroke in patients with PFO could be confirmed in 50% of cases only, underlining the importance of a multidisciplinary evaluation of these patients. A very low ischaemic recurrence rate was observed in the medical therapy group, suggesting that a personalized treatment based on a prespecified diagnostic algorithm yields good clinical results irrespective of the treatment modality. Given the low number of recurrences, larger cohorts may be needed to prove significant differences.

Migraine and percutaneous patent foramen ovale closure: a systematic review and meta-analysis

Background

The association between patent foramen ovale (PFO) and migraine with aura (MA) is well established. However, the benefits of PFO closure are less certain in patients with migraine without aura (MwoA).

Methods

We systematically searched Pubmed for pertinent clinical studies published from January 2000 to July 2015. The primary end-point was the elimination or significant improvement of migraine symptoms after PFO closure.

Results

Upon screening an initial list of 315 publications, we identified eight studies that included 546 patients. Overall, our analysis indicated a significant improvement of migraine in 81% of MA cases compared to only 63% of MwoA cases. The summary odds ratio was 2.5 (95% confidence interval 1.09–5.73), and the benefits of PFO closure were significantly greater for patients with MA compared to patients with MwoA (P = 0.03).

Conclusions

The presence of aura provides a reference standard for the clinical selection of patients with migraine for PFO closure intervention.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-017-0644-9) contains supplementary material, which is available to authorized users.

Effectiveness and Safety of Transcatheter Patent Foramen Ovale Closure for Migraine (EASTFORM) Trial

We evaluated the safety and effectiveness of transcatheter patent foramen ovale (PFO) closure for the treatment of migraine in a Chinese population. This non-randomized clinical trial enrolled 258 consecutive substantial or severe migraineurs with a right-to-left shunt (RLS) (grade II–IV) and grouped subjects according to their election or refusal of PFO closure. Migraine was diagnosed according to the International Classification of Headache Disorders III-beta and evaluated using the Headache Impact Test-6 (HIT-6). In total, 241 participants (125 in the transcatheter closure group and 116 in the control group) were included in the study. In general, the PFO closure procedure was found to be safe. At 1 month after closure, 76.1% of patients returned for c-TCD evaluation; of these, 85.7% were downgraded to negative status or a grade-I shunt. Residual shunts and placebo effects were thought to resolve by 12 months post-procedure, when migraine impact was reported to decrease by 73.6%. Transcatheter PFO closure was demonstrated to be effective for the treatment of migraine by comparing HIT-6 scores between the transcatheter closure and control groups (p < 0.001). Our results suggest that transcatheter PFO closure is a safe and effective approach for the treatment of migraine in the Chinese population, especially in females with constant RLS. Clinical trial no. NCT02127294 (registered on April 29, 2014).

Patent Foramen Ovale and Migraine: Closing the Debate--A Review

BACKGROUND

A link between patent foramen ovale (PFO) and migraine as well as the utility of closure of PFO and its effect on migraine have been subjects of debate. The present review is an effort to gather the available evidence on this topic and formulate recommendations.

METHODS

A systematic search of electronic databases (Medline, Embase, Cochrane Library) was performed. A separate search in associated reference lists of identified studies was done. Observational studies and clinical trials published in English using the International Headache Society criteria for diagnosis of migraine were included in the analysis. The search was performed in 3 categories: prevalence of migraine in patients with PFO, prevalence of PFO in migraine patients, and effect of PFO closure and its effect on migraine. The quality of evidence and strength of recommendations during review of these studies was analyzed.

RESULTS

About 14 observational studies with 2602 subjects who had PFO were identified. Migraine prevalence ranged from 16% to 64%. Another 20 studies reported 2444 patients with migraine; the prevalence of PFO ranged from 15% to 90%. About 20 observational studies (1194 patients) that examined the effect of PFO closure on migraine were identified. Resolution of migraine was reported in 10% to 83% of patients, improvement in 14% to 83%, no change in 1% to 54%, and worsening in 4% to 8%. The overall quality of these observational studies was poor. Finally, 3 randomized clinical trials included a total of 238 patients who underwent PFO closure compared with 234 patients in the control groups. All 3 trials failed to meet their primary end points defined as migraine resolution and greater than 50% reduction in migraine days at 1 year. In 2 of the clinical trials, there was some benefit noted in a small subset of migraine patients with aura, but the numbers were too small to extrapolate the findings to the general migraine population.

CONCLUSIONS

There is no good quality evidence to support a link between migraine and PFO. Closure of PFO for migraine prevention does not significantly reduce the intensity and severity of migraine. We do not recommend the routine use of this procedure in current practice.

A meta-analysis of case-control studies of the association of migraine and patent foramen ovale

OBJECTIVES

To establish quantitative evidence, we performed the first meta-analysis of case-control studies assessing the relationship between migraine and patent foramen ovale (PFO).

METHODS

MEDLINE and EMBASE were searched through April 2015 using PubMed and OVID. Eligible studies were case-control studies reporting PFO (or migraine) prevalence in migraine patients versus no-migraine subjects (or PFO patients versus no-PFO subjects).

RESULTS

Of 395 potentially relevant articles screened initially, 21 eligible studies enrolling a total of 5572 participants were identified and included. Pooled analyses demonstrated statistically significant 3.36-fold migraine-with-aura [odds ratio (OR), 3.36; 95% confidence interval (CI), 2.04-5.55; p<0.00001] and 2.46-fold migraine-with/without-aura prevalence (OR, 2.46; 95% CI, 1.55-3.91; p=0.0001) but statistically non-significant 1.30-fold migraine-without-aura prevalence (OR, 1.30; 95% CI, 0.85-1.99; p=0.22) in PFO patients relative to no-PFO subjects.

CONCLUSIONS

PFO is associated with 3.4-fold migraine-with-aura and 2.5-fold migraine-with/without-aura prevalence but unassociated with migraine-without-aura prevalence.