Transformation into daily migraine with aura following transcutaneous atrial septal defect closure

Disappearance of aura symptoms in patients with hemiplegic migraine after patent foramen ovale closure: a case report and literature review

Hemiplegic migraine (HM) can cause significant functional impairment and negatively affect the quality of life of affected individuals. Emerging evidence suggests an association between migraines and congenital patent foramen ovale (PFO), which is a small opening between the atria of the heart that normally closes shortly after birth. This report describes a 34 years-old woman with sporadic hemiplegic migraine (SHM) who was diagnosed with PFO. Following percutaneous PFO closure, her hemiplegic symptoms disappeared, but her headache exacerbated. After 3 years of follow-up, her headache severity gradually reduced, and the frequency remained consistent at 2-3 times per year with no aura symptoms. This case highlights the dissociation between the resolution of hemiplegic symptoms and the persistence of headaches after PFO closure in sporadic HM. Patients with HM may experience changes in aura symptoms and headache severity after PFO closure. Before performing PFO closure in patients with hemiplegic migraine, the indications should be thoroughly understood.

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.

A New Perspective of Migraine Symptoms in Patients With Congenital Heart Defect

OBJECTIVE

To investigate the association between congenital heart defects (CHDs) and migraine and evaluate the efficacy of transcatheter defect closure from a new perspective.

METHODS

The patients with CHDs who underwent transcatheter defect closure were screened in the medical database of Chinese PLA General Hospital from January 2006 to January 2017. The assessment included basic admission information, the 3-item ID Migraine Screener, and a detailed questionnaire administered by telephone or in an outpatient clinic. Patients were divided into ventricular septal defect (VSD) group and AP group (ie, patients with ASD or PFO) based on the type of defects. The latter group could be further divided into right-to-left shunt (RLS) group and left-to-right (LRS) shunt group. Each group contained 4 subgroups according to their migraine diagnosis before and after defect closure: persistent migraine (PM), relieved migraine (RM), without migraine (WM), and new-onset migraine (NM).

RESULTS

The study recruited total 441 CHDs patients. Most patients in RLS group had migraine before and/or after surgery (76.4%, 42/55) and the proportion of them in NM group was higher than that of in LRS group (23.5%, 4/17 vs 6.8%, 18/266, P = .0418). Although the size of closure device or defect did not show significant differences, the ratios (R = size of closure/size of defect) were significantly higher in NM group than those in WM group (1.40 [1.26, 1.80] vs 1.22 [1.13, 1.38] in AP group, P = .00238; 1.38 [1.23, 1.50] vs 1.22 [1.13, 1.37] in LRS group, P = .024934, respectively). Further logistic regression analysis illustrated that larger R value was a risk factor for NM in AP group (OR 1.48, 95% CI 1.07-2.05, P = .0188). Besides, migraine symptoms decreased significantly after defect closure in PM group among patients with ASD and PFO.

CONCLUSION

This study revealed several associations between migraine and CHDs, especially the large ratio of closure device size to defect size. High-quality randomized controlled trials and animal studies are needed to further investigate and clarify the underlying association between CHDs and migraine.

Migraine Modulation and Debut after Percutaneous Atrial Septal Defect Closure: A Review

INTRODUCTION

Change in migraine headache (MH)-preexisting MH change or development of de novo MH-are known potential complications following percutaneous closure of atrial septal defect (ASD), but consensus on a causal trigger remains elusive.

OBJECTIVES

To expose potential MH triggers linked, mainly by timing and occurrence, to the emergence of de novo MH or change in preexisting MH subsequent to percutaneous ASD closure (pASDC).

METHODS

The literature was systematically searched for studies available in English reporting MH status after pASDC published between January 1, 1990 and November 15, 2015. We determined the number and percentage of patients experiencing MH status change within 7 days post procedure and the cumulative total by final follow-up (Mdn = 12 months).

RESULTS

Twenty-five studies met the inclusion criteria, which accounted for a total of 1,646 pASDC patients. Pre-procedure MH prevalence was 8% (126/1,646). Change in preexisting MH occurred in a total of 72% (91/126), 12% (11/91) within 7-days after pASDC; within follow-up MH improved in 14% (18/126), resolved in 37% (47/126), but persisted in 63% (79/126). De novo MH incidence ranged between 10 (153/1,520) and 18.3% (153/836); 34% incipience (52/153) was within 7-days of pASDC; females accounted for 80% (63/79) of gender differentiated cases; of type distinguished cases, 42% (51/122) were MH without aura (MO) and 58% (71/122) were MH with aura (MA); MH improved in 10% (16/153), resolved in 24% (37/153) but persisted beyond final follow-up in 76% (116/153). Antiplatelet agents were effective modulators of MH in 44% (11/25) studies. Possible adverse MH-predisposing traits were scarce: larger ASD size reported in ~2% (39/1,646) of patients experiencing de novo MH or preexisting MH exacerbation; short aortic rim reported in three de novo MH patients; allergic response to occluder nickel alloy in four patients with MH status change from baseline (de novo or preexisting MH change not specified).

INTERPRETATION

Early intensification of MH status change but later amelioration (virtually paralleling stages of endothelialization), relatively high efficacy of antiplatelet agents, and the emergence of MA as the dominant de novo MH type favor proinflammatory triggers of MH status change after pASDC.

Migraine Symptoms Related to the Percutaneous Closure of An Ostium Secundum Atrial Septal Defect: Report of Four Paediatric Cases and Review of the Literature

Several publications have recently suggested that atrial septal defect may be associated with the physiopathology of headache with migraine-type characteristics. We describe four previously asymptomatic paediatric patients with atrial septal defect who underwent percutaneous Amplatzer septal occluder device implantation and who subsequently developed symptoms compatible with migraine headache. The cases had normal echocardiograms after the intervention and a benign course with headache improvement after several weeks or months. There are paediatric patients with atrial septal defect who may dramatically develop migraine symptoms with or without aura following percutaneous correction of their defect. Large paediatric studies are needed to offer accurate prognoses for children and their families. The possibility of using clopidogrel to treat this type of headache is subject to debate.

Migraine attacks after transcatheter closure of atrial septal defect

Objective

The purpose of our study was to evaluate the effect of atrial septal defect (ASD) closure on migraine headache attacks (MHA).

Methods

A total of 247 patients who underwent percutaneous ASD closure at our facilities were sent a structured questionnaire. We diagnosed MHA according to the criteria of the International Headache Society.

Results

A total of 207 patients were included in the study. New-onset MHA occurred in 23 patients and persisted in 15 at a mean follow-up of 45 months. Of the 29 patients who had MHA prior to ASD closure, 11 reported exacerbation of MHA, 11 reported no change and seven reported improvement within three months after ASD closure. Compared with the patients who had no MHA, patients with de novo MHA were younger and patients with MHA improvement tended to be older. Switching from aspirin to ticlopidine or clopidogrel rapidly aborted frequent MHA in nine patients who had severe symptoms after ASD closure.

Conclusions

These results indicate that Amplatzer device implantation can act as a permanent trigger of MHA in not a few patients, and that age may be an important predictive factor of the influence of ASD closure on MHA.

Systematic review and meta-analysis of currently available clinical evidence on migraine and patent foramen ovale percutaneous closure: much ado about nothing?

OBJECTIVES

To investigate the role of transcatheter closure of patent foramen ovale on the occurrence of migraine.

BACKGROUND

In recent years, a potential relationship between, migraine, stroke, and patent foramen ovale (PFO) has emerged.

METHODS

BioMedCentral, Google Scholar, and PubMed from January 2000 to December 2008 were systematically searched for pertinent clinical studies. Secondary sources were also used. Secondary prevention studies of transcatheter closure for patent foramen ovale were required to include at least more than 10 patients followed for more than 6 months. The primary end-point was the rate of cured or significantly improved migraine after percutaneous PFO closure.

RESULTS

After excluding 637 citations, we finally included a total of 11 studies for a total of 1,306 patients. Forty percent of the subjects included suffered from migraine, while most had a previous history of transient ischemic attack/stroke and were investigated retrospectively. Quantitative synthesis showed that complete cure of migraine in 46% (95% C.I.25-67%), while resolution or significant improvement of migraine occurred in 83% (95% C.I. 78-88%) of cases.

CONCLUSIONS

Notwithstanding the limitations inherent in the primary studies, this systematic review suggests that a significant group of subjects with migraine, in particular if treated after a neurological event, may benefit from percutaneous closure of their patent foramen ovale. However, many questions remain unsolved.

The migraine association with cardiac anomalies, cardiovascular disease, and stroke

Migraine is positively associated with cardio- and cerebrovascular disorders and with structural heart anomalies. Migraine is more prevalent among people with right-to-left shunt by means of patent foramen ovale, atrial septal defects, and pulmonary arteriovenous malformations and among those with altered cardiac anatomy, such as mitral valve prolapse, atrial septal aneurysm, and congenital heart disease. Meanwhile, migraine increases the risk for cardiovascular disease and stroke. Although several hypotheses exist, explanation for these associations is lacking. This article reviews data supporting the association of migraine with right-to-left shunt, structural heart anomalies, cardiovascular disease, and ischemic stroke.

New-onset and persistent migraine early after percutaneous atrial septal defect closure disappear at follow-up

AIMS

Recently we reported that percutaneous atrial septal defect (ASD) closure had no influence on the prevalence of migraine during a short followup period. 12 % of patients however developed a new-onset migraine after the ASD closure. As it has been suggested that the closing device might induce or maintain migraine temporarily, we were interested in the prevalence of migraine at longer follow-up.

METHODS

All 75 patients included in the previous study, received the same structured headache questionnaire. A neurologist, blinded to previous data, diagnosed migraine with or without aura (MA+ or MA-) according to the International Headache Criteria. McNemar paired X2 test was used to evaluate changes in the occurrence of migraine.

RESULTS

Seventy-one patients (94.7%) answer the questionnaire (55 women, mean age at closure 51 +/- 18 years). Mean follow-up time was 52 +/- 13 months. The overall migraine prevalence decreased from 30.7% before to 22.5% after closure (P=0.21). A significant reduction was noted in patients with new-onset migraine early after closure (n=7), where migraine disappeared in 6 patients (P=0.031). In the group with persistent migraine early after closure (n=13), another 6 patients became migraine-free (P=0.031).

CONCLUSION

Percutaneous ASD closure was not related to a significant decrease in overall migraine prevalence. However, new-onset and persistent migraine early after closure disappeared.

Incidence, timing, and predictive factors of new-onset migraine headache attack after transcatheter closure of atrial septal defect or patent foramen ovale

The objectives of this study were to evaluate the incidence, predictive factors, and duration of migraine headache attack (MHA) after transcatheter atrial septal defect (ASD) or patent foramen ovale (PFO) closure. A total of 260 consecutive patients who underwent ASD or PFO closure in our center answered a structured headache questionnaire focused in 3 period times, including (1) at baseline (just before closure), (2) within the 3 months after ASD-PFO closure, and (3) at the last (median 27 months, range 6 to 80 months) follow-up. All questionnaires were evaluated by a neurologist who established the diagnosis of MHA with or without aura, according to International Headache Society criteria. The Amplatzer ASD or PFO device was used in 95% of the patients, and aspirin, for at least 6 months, was the antithrombotic treatment in 91% of the cases. A total of 185 patients (71%) had no history of MHA before ASD-PFO closure, and these constituted the study population (mean age 39 +/- 21 years). MHA occurred in 13 patients (7%) after ASD-PFO closure, with aura in 9 of them. MHA appeared after a median of 10 days (range 0.3 to 30 days) after the procedure and were still present at the last follow-up (23 +/- 17 months) in 9 patients (69%). The median number of MHA within the 3 months after the procedure was 4 per month (interquartile range 1 to 23), and decreased to 1 per month (interquartile range 0.3 to 1) at the latest follow-up (p = 0.03). Compared with the patients who did not develop MHA, patients with MHA after ASD-PFO closure were younger (26 +/- 16 vs 39 +/- 21 years; p = 0.02) and were more likely to have undergone ASD closure (100% vs 58%; p = 0.001). In the multivariate analysis, ASD closure was the only predictor of MHA occurrence after the procedure (odds ratio 7.7; 95% confidence interval 1.5 to 22; p = 0.01). In conclusion, MHA, mostly with aura, occurred in 7% of patients after transcatheter ASD-PFO closure and persisted in most of them after a mean follow-up of 2 years. ASD closure was the only independent predictor of MHA occurrence after the procedure. These results suggest that mechanisms other than device composition are involved in the occurrence of MHA in these cases.

Patent foramen ovale and migraine

Migraine is a common neurological disorder with a great impact on the quality of life and social activities. The patent foramen ovale (PFO) is an intra-atrial right-to-left shunt with a prevalence of 25% in the general population. An increased prevalence is found in patients with migraine, especially in migraine with aura. Percutaneous PFO closure might decrease the prevalence of migraine. However, most of these observational studies were retrospective without a randomized design and the results need to be interpreted with caution. In this review we describe the association between PFO and migraine and the different pathophysiological hypotheses, which have been proposed to explain this relationship.

Foramen ovale perméable et migraine

Recent epidemiological data suggest a bidirectional link between patent foramen ovale (PFO) and migraine with aura (MA) with a relative risk of 2 for PFO in subjects with MA and for MA in subjects with PFO. There is no evidence for a link between PFO and migraine without aura. This link is not systematic and applies only to subsets of PFO, mostly large ones, and to subsets of patients with MA. Although comorbidity cannot be ruled out, it may be that this link is partly causal and that some large PFOs may favor MA attacks in genetically predisposed subjects, by allowing vasoactive substances, platelet emboli or paradoxical emboli to bypass the lung filter and trigger the cortical spreading depression of the aura. The first double blind randomised trial of PFO closure in refractory MA, "MIST", has failed to show a benefit on the primary efficacy end point: cessation of attacks during the analysis period included between 3 and 6 months after the procedure. There is thus at present no scientific reason to look for PFO or to close PFO in migraine patients.

Transcatheter Closure of Patent Foramen Ovale in Patients with Migraine Headache

Our objective is to review the epidemiology and pathophysiology of migraine headache, its association with patent foramen ovale (PFO), and the impact of PFO closure on migraine. Upon reviewing English-language publications listed in MEDLINE relating to migraine headache, PFO, and transcatheter closure of PFO, we selected case series, retrospective and prospective studies relevant to the topic. Primarily retrospective case-control studies demonstrate a link between PFO closure and improvement of migraine headache. Few prospective data confirm the initial results. However, the only randomized, controlled trial finished to date analyzing the effect of PFO closure on migraine failed to reach its primary outcome of resolution of migraine following the intervention. The evidence of a benefit on migraine headache following PFO closure is not convincing, but certainly intriguing. With currently ongoing trials, more information related to this topic can be expected.

The relationship between migraine and right-to-left shunt: Fact or fiction?

The prevalence of a right-to-left shunt, both cardiac and pulmonary, is high in patients with migraines, especially migraine with aura. Percutaneous closure of a right-to-left shunt seems to be associated with a pronounced decrease in the number of migraine attacks or its prevalence. In this review, the relationship between migraine and right-to-left shunting is described by highlighting the different pathophysiologic hypotheses.

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

Migraine is one of the most common neurological disorders and one of the most frequent primary headaches. It imposes a significant burden on the affected individuals, society and health care system. As the etiology and pathophysiology of migraine are not well understood, treatment is largely symptomatic. Patent foramen ovale is a remnant of a fetal circulation and is highly prevalent in the general population. Its presence was linked to several disorders including migraine. The aim of this review was to search in the available data the answer to the question whether the link between migraine and patent foramen ovale is coincidental or whether they represent a pathophysiological entity.

Migraine with aura related to closure of atrial septal defects

A 27-year-old woman had a history of migraine with aura (MWA) since aged 13 years with mostly two attacks per year. After transcutaneous closure of a secundum atrial septal defect (ASD) she suffered from almost daily recurring migraine attacks with prolonged aura symptoms. Exacerbation and new appearance of migraine attacks with aura after transcutaneous closure of ASD have been described previously.

Patent foramen ovale: does it play a role in the pathophysiology of migraine headache?

Migraine headaches have a high prevalence rate in the general population and account for significant morbidity, lost productivity, health care visits, and dollars spent. Increasingly, emerging data show a link between migraine headache, especially migraine headaches with aura, and patent foramen ovale (PFO). Closure of PFO as a cure for migraine headache is a tantalizing idea; this article examines the data supporting that possibility including studies showing improvement in migraine headache after PFO closure and case reports in which migraine headaches worsened after closure of an atrial septal defect.

The influence of percutaneous atrial septal defect closure on the occurrence of migraine

AIMS

Percutaneous patent foramen ovale closure seems to influence migraine. We wanted to observe the effect of percutaneous atrial septal defect (ASD) closure on migraine.

METHODS AND RESULTS

All patients (>16 years of age) with a percutaneous ASD closure were selected from our database (n=114). A questionnaire about headache before and after closure was sent. According to the criteria of the International Headache Society, two neurologists diagnosed migraine with and without aura (MA+ and MA-, respectively). McNemar paired chi(2) and Wilcoxon signed rank tests were used where applicable. Seventy-five patients (66%, 59 females, mean age 51+/-19 years) responded and were included in the study. An Amplatzer ASD occluder was used in all. Median follow-up time was 29 months (IQ1 and IQ3, 18 and 39 months, respectively). The prevalence of MA- and MA+ changed from 19 (14/75) and 11% (8/75), respectively, before closure to 12 (9/75) and 15% (11/75), respectively, after closure (P=0.18 and P=0.55, respectively, vs. before closure). In 12 patients who suffered from migraine before closure (n=4 and 8, MA+ and MA-, respectively), migraine disappeared. In this subgroup, the frequency of migraine attacks decreased significantly (P=0.01). New-onset migraine was noted in 10 patients (n=7 and 3, MA+ and MA-, respectively).

CONCLUSION

Percutaneous ASD closure was not related to a decrease in prevalence of migraine. In a subgroup, patients who suffered from typical migraine before ASD closure, the frequency of migraine attacks decreased significantly. The reason for the new-onset migraine remains unexplained. A larger study sample will be necessary to determine these findings.