Frequency of migraine attacks following stroke starts to decrease before PFO closure

"Migraine side effect" and stroke recurrence in late follow-up after transcatheter patent foramen ovale closure as secondary prevention of cryptogenic thromboembolism

INTRODUCTION

Patent foramen ovale (PFO) is associated with cryptogenic strokes, recurrent transient neurologic deficits, sleep apnea, decompression illness and migraines with aura.

AIM

We verify cryptogenic embolism recurrence after transcatheter PFO closure in patients younger than 55 years old, and determine the prevalence of migraine with aura before and after PFO closure.

MATERIAL AND METHODS

We sent a questionnaire concerning the recurrence of stroke or transient ischemic attack (TIA) and the presence of migraine symptoms before and after PFO closure to 224 consecutive patients (mean age 40.9 ±9 years; 103 men; 108 patients < 40 years old, 116 patients 40-55 years old) after successful PFO transcatheter closure as secondary prevention of cryptogenic embolism.

RESULTS

The mean follow-up period was 37.8 ±32.5 (median 27) months. Stroke or TIA recurred in 6 patients (2.6%), all of whom were over 40 years old at the time of closure. The median time of recurrence was 24 months. Two patients (0.89%) died, but the deaths were not related to the device nor to thromboembolism. Migraine occurred in the study group before closure in 68 (30.4%) patients. After the procedure 55 (80.9%) reported improvement or disappearance of migraine symptoms.

CONCLUSIONS

Recurrent strokes after PFO closure are rare, and they occur more often in patients over 40 years old at the time of closure. The PFO closure results in migraine subsiding or symptoms noticeably ameliorating.

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

OBJECTIVES

To retrospectively evaluate the impact on daily activities of transcatheter closure of patent foramen ovale (PFO) versus medical therapy in patients with migraine and to analyze the role of the residual shunt after PFO closure.

BACKGROUND

While non-controlled observational studies reported an improvement of migraine after PFO closure, a randomized trial has shown no benefit of such an intervention. The role of residual shunt after PFO closure is also poorly known.

METHODS

Out of 217 patients with migraine and echocardiographic evidence of PFO, 89 were managed with percutaneous PFO closure (Group A) while 128 were medically treated (Group B). All MIDAS questionnaires were obtained at the first evaluation and repeated at least 6 months after the index evaluation or after the PFO closure. All the patients were also asked to give a subjective estimate of their migraine status. A postprocedural transcranial Doppler study was available in 70 patients in Group A.

RESULTS

The mean basal MIDAS score did not differ between the two groups (p = 0.859). After a mean follow-up (FU) of 1399 ± 982 days the MIDAS score decreased significantly in both groups (Group A baseline vs FU, p < 0.001; Group B baseline vs FU, p < 0.001), but no differences were observed between groups (p = 0.204). However a significantly higher number of Group A patients reported a perceived clinical benefit or the disappearance of migraine compared to Group B (p < 0.001). Patients with moderate or severe residual right to left shunt were no more likely to have an higher MIDAS score or to complain of migraine than those with mild or no shunt.

CONCLUSIONS

Although the overall evolution of migraine is not significantly different, the abolition of migraine occurs in a larger proportion after PFO closure.

Migraine and stroke: current perspectives

OBJECTIVE

The purpose of this article is to review the latest concepts regarding migraine and ischemic stroke. In addition, focal neurological deficits and MRI changes in migraine patients will be reviewed.

METHODS

A PubMed search of neurological literature pertaining to this study was conducted using specific keyword search terms pertaining to migraine and ischemic stroke.

RESULTS

Migraine, especially with aura, is a relative risk factor for stroke. Neuroimaging demonstrates the posterior circulation as being most vulnerable, although the reason for this distribution is unclear. Factors that may contribute to stroke in migraine include changes during cortical spreading depression with hyper- or hypoperfusion of neural tissue, vasospasm and endothelial dysfunction. Estrogen affects migraine expression as well as cerebral circulation, yet most women with migraine without aura are not at increased risk. Co-morbidity with patent foramen ovale can be mechanism of both disorders via presumed lack of filtration of microemboli or toxic substances; however, closure with reversal of right to left shunt seems to be more beneficial for cryptogenic stroke than migraine. Migraine and stroke are found in specific genetic disorders such as CADASIL, HERNS and MELAS giving clues to genetic factors. Stroke associated with migraine treatments such as ergots or triptans is rare, and usually associated with special circumstances such as overuse or concomitant thrombogenic conditions.

CONCLUSION

Although true migrainous infarction is rare, our understanding of the subtle associations between migraine and cerebrovascular behavior is expanding.

Frequency of migraine headache relief following patent foramen ovale "closure" despite residual right-to-left shunt

Retrospective studies have shown improvement in migraines after patent foramen ovale (PFO) closure. To date, no study has evaluated whether the completeness of closure affects headache status; therefore, the objective of this study was to evaluate the impact of residual right-to-left shunt (RLS) on migraine symptoms after transcatheter PFO closure in migraineurs with and without aura. This was a small-series, single-center, retrospective analysis of late follow-up data on 77 patients with presumed paradoxical embolism and migraine who underwent PFO closure for secondary stroke prevention. Power M-mode transcranial Doppler was used to assess RLS at baseline and 6 and 12 months after closure. A standardized migraine questionnaire was administered at baseline and 6, 12, and 24 months after closure. Fifty-five (71%) patients had migraine with aura. Final closure and migraine status were available for 67 patients; 23 (34%) had incomplete PFO closure, defined as 30 embolic tracks detected at final power M-mode transcranial Doppler examination (median 366 days, 95% confidence interval 332 to 474). Migraine relief (> or = 50% reduction in frequency) was independent of closure status (77% complete closure vs 83% incomplete closure, p = 0.76) at late follow-up (540 days, 95% confidence interval 537 to 711). Migraineurs with aura were 4.5 times more likely to experience migraine relief than migraineurs without aura. In conclusion, migraine relief may occur despite residual RLS after transcatheter PFO closure, which may suggest a reduction in RLS burden below a neuronal threshold that triggers migraine; however, this warrants further investigation. Migraine with aura may be an independent predictor of relief after PFO closure.

Patent foramen ovale and migraine

Results from several observational studies indicate an association between migraine and patent foramen ovale (PFO). Several biological mechanisms have been proposed to explain this link, including shared genetic inheritance. However, there is currently insufficient evidence to support a causal link between PFO and migraine. Although the results of uncontrolled observational studies suggest the PFO closure may have a beneficial effect on migraine frequency, a large randomized trial failed to support such a conclusion. Until there is more evidence from ongoing large controlled trials, PFO closure should not be performed in clinical practice for the prophylaxis of migraine.

Patent foramen ovale, stroke, and cardiovascular disease in migraine

PURPOSE OF REVIEW

We will review the literature on the association between migraine with patent foramen ovale, stroke, and coronary heart disease.

RECENT FINDINGS

The prevalence of patent foramen ovale in patients with migraine with aura is significantly higher than in nonmigraine controls and migraineurs without aura. However, there is currently no evidence to support a causal relationship. Migraine with aura has been consistently associated with increased risk of ischemic stroke in several epidemiologic studies. Migraine with aura is associated with a more unfavourable cardiovascular risk profile and recent data suggest that the association between migraine with aura and stroke may extend to overall cardiovascular disease. Identification of migraine patients at particular risk for stroke or other vascular events is impossible based on current knowledge.

SUMMARY

Migraine with aura and patent foramen ovale have higher coincidences than expected by chance only. It is possible that both conditions are inherited together. Until now there has been no evidence from placebo-controlled randomized trials that closure of patent foramen ovale improves migraine with aura. There is increasing evidence that migraine with aura is not only a risk factor for ischemic stroke but also for myocardial infarction and other ischemic vascular events.