Patent Foramen Ovale, a Possible Cause of Symptomatic Migraine: A Study of 74 Patients with Acute Ischemic Stroke

Abstract

Recent studies reported an increased prevalence of patent foramen ovale (PFO) in patients with migraine with aura (MA+). To investigate the possible relationship between MA+ and paradoxical embolism, we studied the prevalence of both conditions. Investigation of PFO was undertaken in 74 consecutive patients presenting with an acute stroke of undetermined origin. The patients were questioned about MA+ or migraine without aura (MA–) according to the criteria of the International Headache Society. Follow-up was performed to investigate the evolution of MA+ and MA– according to different treatments of stroke. PFO was found in 44 of 74 patients, 16 of whom had MA+ (36%), compared to 4 (13%) MA+ patients without PFO (p = 0.03). Of 25 patients in whom the PFO was considered to play a causal role in the stroke, 13 (52%) had MA+, whereas only 3 (16%) of 19 patients in whom PFO was considered unrelated had MA+ (p = 0.014). Thirty-nine of the patients with MA+ and MA– were studied over a mean follow-up of 13 months. Seven of 15 patients with MA+ and PFO, treated either with surgical closure or anticoagulants, noticed complete disappearance of MA+ attacks. The prevalence of MA+ is high among stroke patients with PFO. In patients with a high presumption of paradoxical embolism, the proportion of MA+ is increased, and this suggests a possible role of this association in the occurrence of the cerebrovascular event. Forty-seven percent of patients with PFO and MA+ reported complete suppression of their aura attacks after surgical closure or anticoagulant treatment. This finding suggests that at least in some patients, MA+ attacks may be due to paradoxical embolism.

The relationship between migraine and right-to-left shunt in children

“…Our results showing higher frequency of RLS/PFO in children with MA(+) are similar to other reports [1,9,29]. It is likely that the association of migraine and PFO is coincidental, because both disorders are frequent.…”

“…In addition, It is possible that unknown genetic factors predispose both to migraine and PFO leading to endocardial and endothelial malformation. Some studies confirmed the association between MA(+) and PFO by suppression of migraine symptoms in some patients after the closure of PFO [10,27,29,32]. However, the association between closure of PFO and decreased attacks of migraine is still a matter of discussion.…”

Pulmonary Vascular Manifestations of Hereditary Hemorrhagic Telangiectasia (Rendu-Osler Disease)

“…A significant reduction in both the prevalence and severity of migraine was reported following transcatheter vaso-occlusion of PAVMs [98]. A similar relationship between right-to-left shunt and migraine has been reported in patients with a patent foramen ovale [99, 100]. Presumably, PAVMs may increase the risk of migraine through the lack of trapping of vasoactive substances by bypassing the pulmonary capillary circulation, or alternatively through a genetic trait associated with both migraine and HHT.…”

Migraine and Patent Foramen Ovale: A Residual Coincidence or a Pathophysiological Intrigue?

“…Others, in a cohort of 74 cryptogenic stroke patients, found PFO in 59% of cases. A history of migraine with aura was more frequent in patients with PFO than in those without (36 vs. 13%, p = 0.03) [82]. Another case-control study included 113 patients with migraine with aura, 53 with migraine without aura, and 25 matched nonmigraine controls.…”