Patent Foramen Ovale and Migraine: A Quantitative Systematic Review

Migraine and the risk of cardiovascular and cerebrovascular events: a meta-analysis of 16 cohort studies including 1 152 407 subjects

OBJECTIVES

To perform an updated meta-analysis to evaluate the long-term cardiovascular and cerebrovascular outcomes among migraineurs.

SETTING

A meta-analysis of cohort studies performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

The MEDLINE, Web of Science and Cochrane Central Register of Controlled Trials databases were searched for relevant articles.

PARTICIPANTS

A total of 16 cohort studies (18 study records) with 394 942 migraineurs and 757 465 non-migraineurs were analysed.

PRIMARY AND SECONDARY OUTCOME MEASURES

Major adverse cardiovascular and cerebrovascular events (MACCE), stroke (ie, ischaemic, haemorrhagic or non-specified), myocardial infarction (MI) and all-cause mortality. The outcomes were reported at the longest available follow-up.

DATA ANALYSIS

Summary-adjusted hazard ratios (HR) were calculated by random-effects Der-Simonian and Liard model. The risk of bias was assessed by the Newcastle-Ottawa Scale.

RESULTS

Migraine was associated with a higher risk of MACCE (adjusted HR 1.42, 95% confidence interval [CI] 1.26 to 1.60, P<0.001, I²=40%) driven by a higher risk of stroke (adjusted HR 1.41, 95% CI 1.25 to 1.61, P<0.001, I²=72%) and MI (adjusted HR 1.23, 95% CI 1.03 to 1.43, P=0.006, I²=59%). There was no difference in the risk of all-cause mortality (adjusted HR 0.93, 95% CI 0.78 to 1.10, P=0.38, I²=91%), with a considerable degree of statistical heterogeneity between the studies. The presence of aura was an effect modifier for stroke (adjusted HR aura 1.56, 95% CI 1.30 to 1.87 vs adjusted HR no aura 1.11, 95% CI 0.94 to 1.31, P _interaction=0.01) and all-cause mortality (adjusted HR aura 1.20, 95% CI 1.12 to 1.30 vs adjusted HR no aura 0.96, 95% CI 0.86 to 1.07, P_interaction<0.001).

CONCLUSION

Migraine headache was associated with an increased long-term risk of cardiovascular and cerebrovascular events. This effect was due to an increased risk of stroke (both ischaemic and haemorrhagic) and MI. There was a moderate to severe degree of heterogeneity for the outcomes, which was partly explained by the presence of aura.

PROSPERO REGISTRATION NUMBER

CRD42016052460.

Hormonal contraceptives and risk of ischemic stroke in women with migraine: a consensus statement from the European Headache Federation (EHF) and the European Society of Contraception and Reproductive Health (ESC)

Several data indicate that migraine, especially migraine with aura, is associated with an increased risk of ischemic stroke and other vascular events. Of concern is whether the risk of ischemic stroke in migraineurs is magnified by the use of hormonal contraceptives. As migraine prevalence is high in women of reproductive age, it is common to face the issue of migraine and hormonal contraceptive use in clinical practice. In this document, we systematically reviewed data about the association between migraine, ischemic stroke and hormonal contraceptive use. Thereafter a consensus procedure among international experts was done to develop statements to support clinical decision making, in terms of cardiovascular safety, for prescription of hormonal contraceptives to women with migraine. Overall, quality of current evidence regarding the risk of ischemic stroke in migraineurs associated with the use of hormonal contraceptives is low. Available data suggest that combined hormonal contraceptive may further increase the risk of ischemic stroke in those who have migraine, specifically migraine with aura. Thus, our current statements privilege safety and provide several suggestions to try to avoid possible risks. As the quality of available data is poor further research is needed on this topic to increase safe use of hormonal contraceptives in women with migraine.

Patent Foramen Ovale and Migraine Headache

Migraine headache is a common and debilitating disease that has a demonstrable association with the presence of patent foramen ovale (PFO) in multiple case series. Closure of PFO has been performed to try to treat migraine with aura, with variable results. Although early trials suggested benefit to PFO closure, these were of poor quality, and subsequent randomized trials have failed to yield positive results. This article discusses the evidence of an association with PFO and migraine headache, and the trials that have so far been performed to assess the benefits of closure.

Migraine and Stroke: What's the Link? What to Do?

Migraine and stroke are common, disabling neurologic disorders, with a high socioeconomic burden. A link between them has been proposed years ago, and various theories have been proposed to explain this bidirectional relation. However, the precise causes remain unclear. We briefly summarize existing hypotheses of this correlation seeking for recommendations for stroke prevention in migraineurs, if any exist. Among the strongest suggested theories of migraine-stroke association are cortical spreading depression, endovascular dysfunction, vasoconstriction, neurogenic inflammation, hypercoagulability, increased prevalence of vascular risk factors, shared genetic defects, cervical artery dissection, and patent foramen ovale. There is no evidence that any preventive therapy in migraineurs should be used to decrease stroke risk, even in most predisposed subset of patients. However, a woman with migraine with aura should be encouraged to cease smoking and avoid taking oral contraceptives with high estrogen doses. We need further investigation to better understand the complexity of migraine-stroke association and to make firm recommendations for the future.

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.

Migraine and risk of perioperative ischemic stroke and hospital readmission: hospital based registry study

OBJECTIVE

 To evaluate whether patients with migraine are at increased risk of perioperative ischemic stroke and whether this may lead to an increased hospital readmission rate.

DESIGN

 Prospective hospital registry study.

SETTING

 Massachusetts General Hospital and two satellite campuses between January 2007 and August 2014.

PARTICIPANTS

 124 558 surgical patients (mean age 52.6 years; 54.5% women).

MAIN OUTCOME MEASURES

 The primary outcome was perioperative ischemic stroke occurring within 30 days after surgery in patients with and without migraine and migraine aura. The secondary outcome was hospital readmission within 30 days of surgery. Exploratory outcomes included post-discharge stroke and strata of neuroanatomical stroke location.

RESULTS

 10 179 (8.2%) patients had any migraine diagnosis, of whom 1278 (12.6%) had migraine with aura and 8901 (87.4%) had migraine without aura. 771 (0.6%) perioperative ischemic strokes occurred within 30 days of surgery. Patients with migraine were at increased risk of perioperative ischemic stroke (adjusted odds ratio 1.75, 95% confidence interval 1.39 to 2.21) compared with patients without migraine. The risk was higher in patients with migraine with aura (adjusted odds ratio 2.61, 1.59 to 4.29) than in those with migraine without aura (1.62, 1.26 to 2.09). The predicted absolute risk is 2.4 (2.1 to 2.8) perioperative ischemic strokes for every 1000 surgical patients. This increases to 4.3 (3.2 to 5.3) for every 1000 patients with any migraine diagnosis, 3.9 (2.9 to 5.0) for migraine without aura, and 6.3 (3.2 to 9.5) for migraine with aura. : Patients with migraine had a higher rate of readmission to hospital within 30 days of discharge (adjusted odds ratio 1.31, 1.22 to 1.41).

CONCLUSIONS

 Surgical patients with a history of migraine are at increased risk of perioperative ischemic stroke and have an increased 30 day hospital readmission rate. Migraine should be considered in the risk assessment for perioperative ischemic stroke.

The relationship between right-to-left shunt and brain white matter lesions in Japanese patients with migraine: a single center study

BACKGROUND

There may be a link between right-to-left shunt (RLs) and brain white matter lesions (WMLs) in patients with migraine. In this study, we assessed the relationship between WMLs and RLs in Japanese migraine patients.

METHODS

A total of 107 consecutive patients with migraine with (MA) and without aura (MWOA) were included in this study. Contrast transcranial Doppler ultrasound was used to detect RLs. WMLs were graded using brain magnetic resonance imaging based on well-established criteria.

FINDINGS

The prevalence of RLs was significantly increased in the WMLs positive group (n = 24) compared with the WMLs negative group (n = 83) (75.0% vs. 47.0%, p = 0.015). In prevalence of WMLs between MA and MWOA patients, there were no statistical differences (p = 0.410). Logistic regression analysis adjusted by age and disease duration of migraine identified an RLs-positive status as the sole determinant for the presence of WMLs (OR = 6.15; 95% CI 1.82-20.8; p = 0.003) CONCLUSION: Our study suggests a possible link between RLs and WMLs in Japanese patients with migraine.

Prevalence of Right to Left Shunts in Japanese Patients with Migraine: A Single-center Study

Objective Several studies have shown an increased prevalence of right-to-left shunt (RLs) in migraine patients, particularly those with aura. However, the prevalence of RLs and its relation to Japanese patients with migraine are unknown. We investigated the prevalence of RLs in Japanese patients with migraine. Methods In total, 112 consecutive patients with migraine were recruited from our headache outpatient clinic. Migraine with aura (MA) and migraine without aura (MWOA) were diagnosed according to the International Classification of Headache Disorders, 3rd edition (beta-version). Contrast transcranial Doppler ultrasound was used to detect RLs, including patent foramen ovale (PFO). Then, the associations between RLs and patients' backgrounds and presence of aura were assessed. Results The overall prevalence of RLs and PFO in migraine patients was 54.5% and 43.8%, respectively. The prevalence of RLs and PFO in the MA group were significantly higher than in the MWOA group (RLs, 62.9% vs. 44.0%, p=0.046; PFO, 54.8% vs. 30.0%, p=0.008). There were no marked differences in the prevalence of large, middle and small shunts between MA and MWOA patients. Compared with the MWOA patients, the MA patients were younger (p=0.013) and had early onset age (p=0.013) and increased prevalence of photophobia (p=0.008). Conclusion RLs were found in over half of the Japanese patients with migraine. Our study suggests a possible link between RLs and MA.

Transcatheter Closure of Patent Foramen Ovale: A Single Center Experience

BACKGROUND

Percutaneous transcatheter closure (PTC) of patent foramen ovale (PFO) is implicated in cryptogenic stroke, transitional ischemic attack (TIA) and treatment of a migraine.

AIM

Our goal was to present our experience in the interventional treatment of PFO, as well as to evaluate the short and mid-term results in patients with closed PFO.

MATERIAL AND METHODS

Transcatheter closure of PFO was performed in 52 patients (67.3% women, mean age 40.7 ± 11.7 years). Patients were interviewed for subjective grading of the intensity of headaches before and after the PFO closure.

RESULTS

During 2 years of follow-up, there was no incidence of new stroke, TIA and/or syncope. Follow-up TCD performed in 35 patients showed complete PFO closure in 20 patients (57.1%). Out of 35 patients, 22 (62.9%) reported having a migraine before the procedure with an intensity of headaches at 8.1 ± 1.9 on a scale from 1 to 10. During 2 years of follow-up, symptoms of a migraine disappeared in 4 (18.2%) and the remaining 18 patients reported the significant decrease in intensity 4.8 ± 2.04 (p = 0.0001). In addition, following PFO closure the incidence of the headaches decreased significantly (p = 0.0001).

CONCLUSIONS

Percutaneous transcatheter closure of PFO is a safe and effective procedure showing mid-term relief of neurological symptoms in patients as well as significant reduction of migraine symptoms.

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).

Ischemic stroke subtypes and migraine with visual aura in the ARIC study

OBJECTIVE

To investigate the association among migraine, ischemic stroke, and stroke subtypes in the Atherosclerosis Risk in Communities (ARIC) study.

METHODS

In this ongoing, prospective, longitudinal community-based cohort study, participants were given an interview ascertaining migraine history in 1993-1995, and were followed for all vascular events, including stroke. All stroke events over the subsequent 20 years were adjudicated and classified into stroke subtypes by standard definitions. Cox proportional hazards models adjusted for stroke risk factors were used to study the relationship between migraine and ischemic stroke, overall, as well as stroke subtypes (cardioembolic, lacunar, or thrombotic).

RESULTS

We identified 1,622 migraineurs among 12,758 participants. Mean age of the study population at the 3rd clinical visit was 59 years. When compared to nonheadache participants, there was a significant association between migraine with visual aura and ischemic stroke (hazard ratio [HR] 1.7, 95% confidence interval [CI] 1.2-2.6, p = 0.008). Migraine without visual aura was not significantly associated with ischemic stroke (HR 1.2, CI 1.0-1.8, p = 0.28) when compared to nonheadache participants. Among the 3 subtypes of ischemic stroke evaluated, migraine with visual aura was significantly associated only with cardioembolic stroke (HR 3.7, 95% CI 1.6-8.7, p = 0.003).

CONCLUSION

In participants with migraine with visual aura in late middle age, increased risk of cardioembolic stroke was observed. Migraine with visual aura was linked to increased stroke risk, while migraine without visual aura was not, over the period of 20 years. These results are specific to older migraineurs.

Increased prevalence of potential right-to-left shunting in children with sickle cell anaemia and stroke

'Paradoxical' embolization via intracardiac or intrapulmonary right-to-left shunts (RLS) is an established cause of stroke. Hypercoagulable states and increased right heart pressure, which both occur in sickle cell anaemia (SCA), predispose to paradoxical embolization. We hypothesized that children with SCA and overt stroke (SCA + stroke) have an increased prevalence of potential RLS. We performed contrasted transthoracic echocardiograms on 147 children (aged 2-19 years) with SCA + stroke) mean age 12·7 ± 4·8 years, 54·4% male) and a control group without SCA or stroke (n = 123; mean age 12·1 ± 4·9 years, 53·3% male). RLS was defined as any potential RLS detected by any method, including intrapulmonary shunting. Echocardiograms were masked and adjudicated centrally. The prevalence of potential RLS was significantly higher in the SCA+stroke group than controls (45·6% vs. 23·6%, P < 0·001). The odds ratio for potential RLS in the SCA + stroke group was 2·7 (95% confidence interval: 1·6-4·6) vs controls. In post hoc analyses, the SCA + stroke group had a higher prevalence of intrapulmonary (23·8% vs. 5·7%, P < 0·001) but not intracardiac shunting (21·8% vs. 18·7%, P = 0·533). SCA patients with potential RLS were more likely to report headache at stroke onset than those without. Intrapulmonary and intracardiac shunting may be an overlooked, independent and potentially modifiable risk factor for stroke in SCA.

No Relationship Between Patent Foramen Ovale and Migraine Frequency

BACKGROUND

Pathophysiology of migraine is not fully known. A link has been proposed between migraine and patent foramen ovale (PFO). However, there are conflicting data regarding the causal relationship between PFO and migraine.

OBJECTIVE

To test a potential association between migraine frequency and PFO by way of an observational, single-center, case-controlled study.

METHODS

We studied a total of 130 chronic migraine (CM) and 53 episodic migraine (EM) patients. Transcranial Doppler with agitated saline injection was used to evaluate the presence and degree of PFO. PFO was judged to be present if any signal was detected. The degree of PFO during rest and Valsalva was quantified as follows: small (1-10 microbubbles [MB]), medium (10-25 MB), or large (>25 MB with shower or curtain pattern). PFO detected at rest were considered permanent, while those detected during Valsalva maneuver were classified as latent.

RESULTS

The prevalence of PFO was similar in CM and EM patients (53.1% [44.1-62.2] vs 54.7% [40.3-69.1], P = .871). PFO size was significantly larger in the EM group compared to the CM group (35.8% vs 20.3%, P = .037). The presence of permanent PFO was also significantly higher in EM compared to CM (37.7% vs 22.7%, P = .044). No differences were found according to the presence of aura.

CONCLUSION

This study indicates that PFO is not more common or larger in CM than in EM patients. These findings do not support a relationship between PFO and migraine frequency.

The Migraine-Stroke Connection

Migraine and stroke are common neurovascular disorders which share underlying physiological processes. Increased risks of ischemic stroke, hemorrhagic stroke, and subclinical ischemic lesions have been consistently found in migraineurs. Three possible associations are suggested. One is that underlying pathophysiology of migraine can lead to ischemic stroke. Second, common comorbidities between migraine and stroke can be present. Lastly, some syndromes can manifest with both migraine-like headache and cerebrovascular disease. Future studies should be targeted on bidirectional influence of migraine on different stroke mechanisms and optimal prevention of stroke in migraine patients.

Is the search for right-to-left shunt still worthwhile?

OBJECTIVES

Patent foramen ovale (PFO) is a common disembryogenic defect with well-attested prevalence but dubious etiopathogenetic linkage with cryptogenic stroke and different clinical conditions. Transcranial color-coded Doppler (TCCD) assures high accuracy in diagnosing right-to-left shunt (RLS) and its functional aspects. Aim of the study was to evaluate RLS prevalence and degree in subjects submitted to TCCD for conditions theoretically associated or caused by paradoxical embolism to the brain.

METHODS

PFO assessment, performed in 10 major diagnostic categories and a control group, followed a standardized protocol with a 10 or 20 microbubbles (MB) cutoff to identify any or only large RLS, respectively.

RESULTS

Among 2113 patients, a significant larger RLS prevalence was found in stroke (53.3%), TIA (45.7%) and migraine with aura (39.7%) when compared with non-migraineurs controls (25.5%). RLS degree was significantly higher in stroke and TIA patients: The ROC curve from MB load data helped to identify new cutoff values for both normal breathing (42 MB) and Valsalva (139 MB) tests. From logistic regression, a family history for PFO, ASA, and male gender appeared independent predictors of a RLS. By contrast, RLS seemed independent of white matter abnormalities presence on brain neuroimaging or stroke mimics.

CONCLUSIONS

In addition to recently defined criteria, genetically determined inheritable traits and epidemiologic characteristics (male gender) should be taken into account when assessing PFO and related cerebrovascular risk profile. A newly defined threshold in TCCD MB count is suggested to discriminate shunts related to stroke and TIA from innocent ones.

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.

Percutaneous closure of patent foramen ovale in migraine with aura, a randomized controlled trial

AIMS

Migraine with aura and patent foramen ovale (PFO) are associated. The Percutaneous Closure of PFO in Migraine with Aura (PRIMA) trial is a multicentre, randomized trial to investigate the effect of percutaneous PFO closure in patients refractory to medical treatment.

METHODS

Migraine with aura patients and PFO who were unresponsive to preventive medications were randomized to PFO closure or medical treatment. Both groups were given acetylsalicylic acid 75-100 mg/day for 6 months and clopidogrel 75 mg/day for 3 months. The primary endpoint was reduction in monthly migraine days during months 9-12 after randomization compared with a 3-month baseline phase before randomization. The committee reviewing the headache diaries were blinded to treatment assignment.

RESULTS

One hundred and seven patients were randomly allocated to treatment with an Amplatzer PFO Occluder (N = 53) or control with medical management (N = 54). The trial was terminated prematurely because of slow enrolment. Eighty-three patients (40 occluder, 43 control) completed 12-month follow-up. Mean migraine days at baseline were 8 (±4.7 SD) in the closure group and 8.3 (±2.4) in controls. The primary endpoint was negative with -2.9 days after PFO closure vs. -1.7 days in control group (P = 0.17). Patent foramen ovale closure caused five adverse events without permanent sequelae.

CONCLUSION

In patients with refractory migraine with aura and PFO, PFO closure did not reduce overall monthly migraine days.

Migraine with aura: which patients are most at risk of stroke?

The complex association between migraine (M) and ischemic stroke (IS) is discussed. Epidemiological studies and meta-analyses show that M with aura (MA) and not M without aura, doubles the risk of IS. The risk is higher for female gender, young age and higher headache attacks frequency. Smoking habit and oral contraceptives, especially if associated, increase stroke risk. The underlying pathogenetic mechanisms are not completely understood, but it is hypothesized that a particular brain susceptibility to cortical spread depression could explain the association between MA and IS. The absolute risk of IS in migraineurs is relatively low and an antithrombotic primary prevention is not indicated, but it is mandatory to investigate and treat associated risk factors for IS and, in young MA women, consider only progestinic oral contraceptives, if needed, and smoking cessation.

Migraine with aura and patent foramen ovale: myth or reality?

Several observational studies report that subjects with migraine with aura have a higher prevalence of right-to left shunt, commonly due to patent foramen ovale, and that patent foramen ovale is more prevalent in subjects with migraine with aura. Although migraine without aura has been less extensively studied, it does not seem to be associated with an increased prevalence of right-to left shunt. The mechanism that underlies the possible relationship between patent foramen ovale and migraine with aura remains speculative. The proposed mechanisms are migraine-triggering vasoactive chemicals bypassing the pulmonary filter and reaching the cerebral circulation and paradoxical microembolization. However, it is unclear, at this time, if there is a causal or comorbid association between the two conditions. In some families atrial shunts show a dominant inheritance that seems to be linked to inheritance of migraine with aura. Migraine with aura is an independent risk factor for ischemic stroke, and patent foramen ovale is present more frequently in patients with cryptogenic stroke than in controls. At this moment, there is no convincing evidence that excess stroke risk of migraine is simply mediated by patent foramen ovale through paradoxical embolism. Several non-controlled studies suggest that closure of the foramen ovale significantly reduces attack frequency in migraine patient, but the only prospective placebo-controlled trial does not support these results. Patent foramen ovale closure, at present, is not indicated as a treatment for migraine in clinical practice.

Migraine aura: new ideas about cause, classification, and clinical significance

PURPOSE OF REVIEW

The migraine aura is a dramatic spontaneous change in brain activity resulting in a variety of transient neurological symptoms. The purpose of this review is to address recent advances in the understanding of aura and its role in migraine.

RECENT FINDINGS

The formal classification of migraine aura is becoming both broader and more detailed. Traditionally viewed as a primary event that triggers a migraine attack, studies regarding the timing of aura relative to other symptoms of migraine indicate that it may not in fact play a primary role in initiating an attack. Careful recording and analysis of visual aura symptoms provides new insight into the initiation and propagation of the underlying brain phenomenon, and the different regions of visual cortex that produce different visual perceptions. Migraine with aura may have different responses to acute and preventive therapies.

SUMMARY

There has been significant evolution of concepts regarding the causes of migraine aura, how it is best defined, and how it fits into the picture of the migraine disorder as a whole. Regardless of its exact role in the genesis of migraine, an increased understanding of aura has the potential to provide important new insight into not only migraine but also fundamental mechanisms of brain physiology.

Influence of transcatheter closure of atrial communication on migraine headache in patients with ischemic stroke

Some types of migraine are associated with ischemic stroke. Although a right-to-left communication is linked with ischemic stroke, a causal relationship between migraine and right-to-left communication remains unclear. Furthermore, the efficacy of transcatheter closure of atrial communication on migraine is controversial. We aimed to evaluate the influence of transcatheter closure of atrial communication on migraine in patients with ischemic stroke. Thirty-eight consecutive patients with ischemic stroke who underwent transcatheter closure of atrial communication were enrolled. The prevalence, frequency, and severity of migraine were prospectively evaluated at baseline, 3 months, and >6 months after the procedure. Changes in migraine after the procedure were classified according to the frequency and severity of migraine: disappeared, improved, no-change, and worsening. Nineteen (50 %) of 38 patients suffered from migraine at baseline. No significant differences were observed in age, comorbidities, defect diameter, and atrial septal aneurysm between patients with migraine and patients without migraine. Among the 19 patients with migraine, migraine disappeared in 10 (53 %) patients and improved in 8 (42 %) patients at 3 months after transcatheter closure of atrial communication. At mean follow-up of 38 ± 28 months after the procedure, migraine disappeared in 12 (63 %) patients and improved in five (26 %) patients. No patients experienced worsening of migraine during the follow-up period. New-onset migraine was not observed in patients without migraine. Migraine is complicated in a half of patients with ischemic stroke related to atrial communication. Such migraine may disappear or improve after transcatheter closure of atrial communication.

Patent foramen ovale: Unanswered questions

The foramen ovale is a remnant of the fetal circulation that remains patent in 20-25% of the adult population. Although long overlooked as a potential pathway that could produce pathologic conditions, the presence of a patent foramen ovale (PFO) has been associated with a higher than expected frequency in a variety of clinical syndromes including cryptogenic stroke, migraines, sleep apnea, platypnea-orthodeoxia, deep sea diving associated decompression illness, and high altitude pulmonary edema. A unifying hypothesis is that a chemical or particulate matter from the venous circulation crosses the PFO conduit between the right and left atria to produce a variety of clinical syndromes. Although observational studies suggest a therapeutic benefit of PFO closure compared to medical therapy alone in patients with cryptogenic stroke, 3 randomized controlled trials (RCTs) did not confirm the superiority of PFO closure for the secondary prevention of stroke. However, meta-analyses of these RCTs demonstrate a significant benefit of PFO closure over medical therapy alone. Similarly, observational studies provide support for PFO closure for symptomatic relief of migraines. But one controversial randomized study failed to replicate the results of the observational studies while another two demonstrated a partial benefit. The goal of this review is to discuss the clinical conditions associated with PFO and provide internists and primary care physicians with current data on PFO trials, and clinical insight to help guide their patients who are found to have a PFO on echocardiographic testing.

Age-specific association of migraine with cryptogenic TIA and stroke: Population-based study

OBJECTIVE

To determine whether there is an association between previous migraine and cryptogenic TIA or ischemic stroke at older ages.

METHODS

We determined the age-specific associations of history of migraine and Trial of Org 10172 in Acute Stroke Treatment (TOAST) subtype of TIA and ischemic stroke in a population-based cohort study (Oxford Vascular Study; 2002-2012).

RESULTS

Among 1,810 eligible patients with TIA or ischemic stroke, 668 (36.9%) had cryptogenic events, of whom 187 (28.0%) had previous migraine. Migraine was more commonly associated with cryptogenic events than with those of known etiology (odds ratio [OR] 1.73, 95% confidence interval [CI] 1.38-2.16, p < 0.0001; cardioembolic 2.00, 1.50-2.66, p < 0.0001; large artery 1.75, 1.20-2.53, p = 0.003; small vessel 1.32, 0.95-1.83, p = 0.096). The association of migraine with cryptogenic events was independent of age, sex, and all measured vascular risk factors (RFs) (adjusted OR 1.68, 1.33-2.13, p < 0.0001) and was strongest at older ages (<55 years, OR 1.11, 0.55-2.23; 55-64 years, 1.48, 0.83-2.63; ≥65 years, 1.81, 1.39-2.36) and in patients without vascular RFs (0 RFs OR 2.62, 1.33-5.15; 1 RF 2.01, 1.35-3.01; 2 RFs 1.80, 1.21-2.68; 3 RFs 1.21, 0.71-2.07; 4 RFs 0.92, 0.28-2.99). Results were consistent for migraine with or without aura and for analyses excluding TIA or stratified by sex or vascular territory of event.

CONCLUSIONS

In this population-based study of stroke etiology stratified by age, migraine was most strongly associated with cryptogenic TIA and ischemic stroke, particularly at older ages, suggesting a causal role or a shared etiology.

Do interictal microembolic signals play a role in higher cortical dysfunction during migraine aura?

Introduction

The aim of this study was to evaluate the prevalence and clinical impact of interictal microembolic signals (MES) in patients suffering from migraine with higher cortical dysfunction (HCD), such as language and memory impairment, during an aura.

Patients and methods

This study was carried out on 34 migraineurs with language and memory impairment during aura (HCD group), 31 migraineurs with only visual or visual and somatosensory symptoms during aura (Control group I), and 34 healthy controls (Control group II). We used a Doppler instrument to detect microemboli. Demographic data, disease features and the detection of MES between these groups, as well as the predictors of HCD during the aura, were analyzed.

Results

The duration of aura was longer and the frequency of aura was higher among patients with language and memory impairment during aura compared to Control group I. MES was detected in 29.4% patients from the HCD group, which was significantly higher compared to 3.2% in Control group I and 5.9% in Control group II. Regarding the absence or presence of MES, demographic and aura features were not different in the HCD subgroups. A longer duration of aura, the presence of somatosensory symptoms during the aura and the presence of interictal MES were independent predictors of HCD during the aura.

Conclusion

The present findings indicate that HCD and MES are related in patients with migraine with aura. Further research is needed to better understand the exact pathophysiological mechanism.

Clinical impact of migraine for the management of glaucoma patients

Migraine is a common and debilitating primary headache disorder that affects 10-15% of the general population, particularly people of working age. Migraine is relevant to providers of clinical eye-care because migraine attacks are associated with a range of visual sensory symptoms, and because of growing evidence that the results of standard tests of visual function necessary for the diagnosis and monitoring of glaucoma (visual fields, electrophysiology, ocular imaging) can be abnormal due to migraine. These abnormalities are measureable in-between migraine events (the interictal period), despite patients being asymptomatic and otherwise healthy. This picture is further complicated by epidemiological data that suggests an increased prevalence of migraine in patients with glaucoma, particularly in patients with normal tension glaucoma. We discuss how migraine, as a co-morbidity, can confound the results and interpretation of clinical tests that form part of contemporary glaucoma evaluation, and provide practical evidence-based recommendations for the clinical testing and management of patients with migraine who attend eye-care settings.

Prevalence of migraine headache in an in-patient stroke population

INTRODUCTION

Migraine, especially with aura, is a risk factor for ischemic stroke. In this study, we investigated descriptive data and prevalence of migraine in an in-patient stroke population.

MATERIALS AND METHODS

Patients with acute cerebrovascular disease (CVD) admitted to the stroke unit during a 6-month period were recruited. Prevalence of migraine was assessed using a structured questionnaire. Additional clinical data regarding risk factors for CVD were evaluated for all responding patients.

RESULTS

A total of 229 patients received a questionnaire and 175 answers were collected (response frequency of 76.4%). Responders matched the initial cohort regarding distribution of age, sex, and type of stroke. Thirty-six cases (20.6%) fulfilled the criteria for migraine or probable migraine according to the 2nd edition of the International Headache Classification (ICHD-2). Sixty percent of migraine patients had migraine with aura. Stroke patients with migraine were younger (P = 0.007), the presence of patent foramen ovale (PFO) was significantly increased (P = 0.008), and atrial fibrillation was less common (P = 0.048). There were no other differences between patients with and without migraine headache regarding conventional risk factors.

CONCLUSIONS

The prevalence of migraine in this hospital-based stroke cohort was comparable to the estimated prevalence of migraine usually described in population studies. In our study population, the prevalence of migraine with aura was higher than expected. The increased prevalence of PFO in patients with migraine headache corresponds well to previous population studies.

Diagnosis and management of migraines and migraine variants

Migraine headache is a neurologic disorder that occurs in 18% of women and 6% of men. Adults and children with mild to moderate migraine headaches seeking acute therapy should be treated with nonsteroidal anti-inflammatory drugs because of the efficacy, cost, and decreased side effects. Some children and adults require preventive therapy (those with headaches lasting >12 h, those patients with >4 headaches in 1 month, those with headaches that affect their ability to function). Studies have shown that early treatment with large doses of medication work well for the treatment of moderate to severe migraine headache.

Late-life migraine accompaniments: A narrative review

BACKGROUND

Migraine is one of the most common chronic neurological disorders. In 1980, C. Miller Fisher described late-life migraine accompaniments as transient neurological episodes in older individuals that mimic transient ischemic attacks. There has not been an update on the underlying nature and etiology of late-life migraine accompanimentsd since the original description.

PURPOSE

The purpose of this article is to provide a comprehensive and extensive review of the late-life migraine accompaniments including the epidemiology, clinical characteristics, differential diagnosis, and treatment.

METHODS

Literature searches were performed in MEDLINE®, PubMed, Cochrane Library, and EMBASE databases for publications from 1941 to July 2014. The search terms "Migraine accompaniments," "Late life migraine," "Migraine with aura," "Typical aura without headache," "Migraine equivalents," "Acephalic migraine," "Elderly migraine," and "Transient neurological episodes" were used.

CONCLUSION

Late-life onset of migraine with aura is not rare in clinical practice and can occur without headache, especially in elderly individuals. Visual symptoms are the most common presentation, followed respectively by sensory, aphasic, and motor symptoms. Gradual evolution, the march of transient neurological deficits over several minutes and serial progression from one symptom to another in succession are typical clinical features for late-life migraine accompaniments. Transient neurological disturbances in migraine aura can mimic other serious conditions and can be easily misdiagnosed. Careful clinical correlation and appropriate investigations are essential to exclude secondary causes. Treatments are limited and still inconsistent.

"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.

Migraine and stroke: "vascular" comorbidity

Several comorbidities are associated to migraine. Recent meta-analyses have consistently demonstrated a relationship between migraine and stroke, which is well-defined for ischemic stroke and migraine with aura (MA), even stronger in females on oral contraceptives or smokers. However, there seems to be no clear-cut association between stroke in migraineurs and the common vascular risk factors, at least in the young adult population. Migraineurs also run an increased risk of hemorrhagic stroke, while the association between migraine and cardiovascular disease remains poorly defined. Another aspect is the relationship between migraine and the presence of silent brain lesions. It has been demonstrated that there is an increased frequency of ischemic lesions in the white matter of migraineurs, especially silent infarcts in the posterior circulation territory in patients with at least 10 attacks per month. Although there is a higher prevalence of patent foramen ovale (PFO) in migraineurs, the relationship between migraine and PFO remains controversial and PFO closure is not a recommended procedure to prevent migraine. As an increased frequency of cervical artery dissections has been observed in migrainous patients, it has been hypothesized that migraine may represent a predisposing factor for cervical artery dissection. There still remains the question as to whether migraine should be considered a true “vascular disease” or if the comorbidity between migraine and cerebrovascular disease may have underlying shared risk factors or pathophysiological mechanisms. Although further studies are required to clarify this issue, current evidence supports a clinical management where MA patients should be screened for other concomitant vascular risk factors and treated accordingly.

Migraine and stroke: in search of shared mechanisms

BACKGROUND

Migraine, particularly with aura, increases the risk for ischemic stroke, at least in a subset of patients. The underlying mechanisms are poorly understood and probably multifactorial.

METHODS

We carried out an extended literature review of experimental and clinical evidence supporting the association between migraine and ischemic stroke to identify potential mechanisms that can explain the association.

RESULTS

Observational, imaging and genetic evidence support a link between migraine and ischemic stroke. Based on clinical and experimental data, we propose mechanistic hypotheses to explain the link, such as microembolic triggers of migraine and enhanced sensitivity to ischemic injury in migraineurs.

DISCUSSION

We discuss the possible practical implications of clinical and experimental data, such as aggressive risk factor screening and management, stroke prophylaxis and specific acute stroke management in migraineurs. However, evidence from prospective clinical trials is required before modifying the practice in this patient population.

Chaos and commotion in the wake of cortical spreading depression and spreading depolarizations

Punctuated episodes of spreading depolarizations erupt in the brain, encumbering tissue structure and function, and raising fascinating unanswered questions concerning their initiation and propagation. Linked to migraine aura and headache, cortical spreading depression contributes to the morbidity in the world's migraine with aura population. Even more ominously, erupting spreading depolarizations accelerate tissue damage during brain injury. The once-held view that spreading depolarizations may not exist in the human brain has changed, largely because of the discovery of migraine genes that confer cortical spreading depression susceptibility, the application of sophisticated imaging tools and efforts to interrogate their impact in the acutely injured human brain.

Spreading depolarization may link migraine and stroke

Migraine increases the risk of stroke, particularly in young and otherwise healthy adults. Being the most frequent neurological condition, migraine prevalence is on a par with that of other common stroke risk factors, such as diabetes or hypertension. Several patterns of association have emerged: (1) migraine and stroke share a common association (eg, vasculopathies, patent foramen ovale, or pulmonary A-V malformations); (2) injury to the arterial wall such as acute arterial dissections can present as migraine aura attacks or stroke; (3) strokes rarely develop during a migraine attack, as described for "migrainous stroke." Increasing experimental evidence suggests that cerebral hyperexcitability and enhanced susceptibility to spreading depolarization, the electrophysiologic event underlying migraine, may serve as a mechanism underlying the migraine-stroke association. Mice carrying human vascular or neuronal migraine mutations exhibit an enhanced susceptibility to spreading depolarization while being particularly vulnerable to cerebral ischemia. The severe stroke phenotype in migraine mutant mice can be prevented by suppressing spreading depolarization. If confirmed in the clinical setting, inhibiting spreading depolarization might protect migraineurs at stroke risk as well as decrease attacks of migraine.

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.

Dysmetropsia and Cotard's syndrome due to migrainous infarction – or not?

Introduction

Migrainous infarction accounts for 12.8% of ischemic strokes of unusual etiology.

Case report

A 59-year-old woman with longstanding migraine with aura experienced what appeared to be migrainous infarction characterized by dysmetropsia and transient Cotard’s syndrome. Imaging demonstrated right temporal-parietal-occipital changes with apparent cortical laminar necrosis.

Conclusion

The spectrum of the pathophysiology of migrainous infarction has not been established; however, cortical spreading depression may explain the appearance of imaging findings that do not obey a vascular territory.

Headaches caused by vascular disorders

The clinical association between stroke and headache is complex, ranging from the largely irrelevant to the highly specific. The incidence and clinical relevance of acute headache are highly dependent on stroke subtype and etiology. In this article the issue of headache accompanying acute stroke is addressed in some detail.

How to Understand Patent Foramen Ovale Clinical Significance: Part I

Patent foramen ovale (PFO) is a remnant of fetal circulation commonly found in healthy population. However, a large number of clinical conditions have been linked to PFO, the most important being ischemic strokes of undetermined cause (cryptogenic strokes) and migraine, especially migraine with aura. Coexistent atrial septal aneurysm, size of PFO, degree of the shunt, shunt at rest, pelvic deep vein thrombosis, and prothrombotic states (G20210A prothrombin gene mutation, Factor V Leiden mutation, MTHFR: C677T, basal homocystine, recent surgery, trauma, or use of contraceptives) could enhance stroke risk in subjects with PFO. Owing to the complexity of this issue, for any individual presenting with a PFO, particularly in the setting of cryptogenic stroke, it is not clear whether the PFO is pathogenically related to the neurological event or an incidental finding. Thus, a heart-brain team, which individually plans the best strategy, in accordance with neuroimaging findings and anatomical characteristics of PFO, is strongly recommended. In the first part of this review, we discuss the embryologic and anatomic features of PFO, the diagnostic techniques for its identification and evaluation, and the relationship between PFO and neurological syndromes. A special attention is made to provide some key points, useful in a daily clinical practice, which summarize how better we understand PFO clinical significance