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Tang Y, Sun H, Plummer C, Vogrin SJ, Li H, Li Y, Chen L. Association between patent foramen ovale and migraine: evidence from a resting-state fMRI study. Brain Imaging Behav 2024:10.1007/s11682-024-00868-9. [PMID: 38381323 DOI: 10.1007/s11682-024-00868-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 02/22/2024]
Abstract
A relationship between migraine without aura (MO) and patent foramen ovale (PFO) has been observed, but the neural basis underlying this relationship remains elusive. Utilizing independent component analysis via functional magnetic resonance imaging, we examined functional connectivity (FC) within and across networks in 146 patients with MO (75 patients with and 71 patients without PFO) and 70 healthy controls (35 patients each with and without PFO) to elucidate the individual effects of MO and PFO, as well as their interaction, on brain functional networks. The main effect of PFO manifested exclusively in the FC among the visual, auditory, default mode, dorsal attention and salience networks. Furthermore, the interaction effect between MO and PFO was discerned in brain clusters of the left frontoparietal network and lingual gyrus network, as well as the internetwork FC between the left frontoparietal network and the default mode network (DMN), the occipital pole and medial visual networks, and the dorsal attention and salience networks. Our findings suggest that the presence of a PFO shunt in patients with MO is accompanied by various FC changes within and across networks. These changes elucidate the intricate mechanisms linked to PFO-associated migraines and provide a basis for identifying novel noninvasive biomarkers.
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Affiliation(s)
- Yusha Tang
- Department of Neurology, West China Hospital of Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan Province, 610041, China
| | - Huaiqiang Sun
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Chris Plummer
- Department of Neuroimaging, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Simon J Vogrin
- Department of Neuroimaging, Swinburne University of Technology, Hawthorn, VIC, Australia
- Department of Neurosciences, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Hua Li
- Department of Neurology, West China Hospital of Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan Province, 610041, China
| | - Yajiao Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lei Chen
- Department of Neurology, West China Hospital of Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan Province, 610041, China.
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Thomsen AV, Ashina H, Al-Khazali HM, Rose K, Christensen RH, Amin FM, Ashina M. Clinical features of migraine with aura: a REFORM study. J Headache Pain 2024; 25:22. [PMID: 38350851 PMCID: PMC10865578 DOI: 10.1186/s10194-024-01718-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/16/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND About one-third of persons with migraine experience transient neurologic symptoms, referred to as aura. Despite its widespread prevalence, comprehensive clinical descriptions of migraine with aura remain sparse. Therefore, we aimed to provide an in-depth phenotypic analysis of aura symptoms and characteristics in a cross-sectional study of a large sample of adults diagnosed with migraine with aura. METHODS Data were extracted from the baseline characteristics of participants in the Registry for Migraine (REFORM) study - a single-center, prospective, longitudinal cohort study. Participants were adults diagnosed with migraine aura, reporting ≥ 4 monthly migraine days in the preceding 3 months. Trained personnel conducted in-person semi-structured interviews, capturing details on the nature, duration, localization, and progression of individual aura symptoms. RESULTS Of the 227 enrolled participants with migraine with aura, the mean age was 41.1 years, with a predominant female representation (n = 205 [90.3%]). Visual aura was present in 215 (94.7%) participants, somatosensory aura in 81 (35.7%), and speech and/or language aura in 31 (13.7%). A single type of aura was observed in 148 (65.2%) participants, whilst 79 (34.8%) reported multiple aura types. Most participants (n = 220 [96.9%]) described their aura symptoms as positive or gradually spreading. Headache in relation to aura was noted by 218 (96.0%) participants, with 177 (80.8%) stating that the onset of aura symptoms preceded the onset of headache. CONCLUSIONS This study offers a detailed clinical depiction of persons with migraine with aura, who were predominantly enrolled from a tertiary care unit. The findings highlight potential gaps in the available literature on migraine with aura and should bolster clinicians' acumen in diagnosing migraine with aura in clinical settings.
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Affiliation(s)
- Andreas Vinther Thomsen
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Håkan Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Brain and Spinal Cord Injury, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Haidar M Al-Khazali
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kathrine Rose
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Rune Häckert Christensen
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Faisal Mohammad Amin
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Brain and Spinal Cord Injury, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Messoud Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
- Danish Knowledge Center On Headache Disorders, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
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Xu Y, Liu R. The prevalence of positive right to left shunt in migraine patients with and without aura: A new single-center study in China. Clin Neurol Neurosurg 2023; 235:108020. [PMID: 38344972 DOI: 10.1016/j.clineuro.2023.108020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/01/2023] [Accepted: 10/22/2023] [Indexed: 02/15/2024]
Abstract
BACKGROUND Recently, many studies have reported that there may be association between positive right-to-left shunt (RLS) and migraine, especially Migraine with aura (MA) patients. However, these researches are mostly limited in Western country. And the latest study describing the prevalence of RLS in Chinese patients with migraine was conducted five years ago. It indicated the significant higher rate of positive RLS in MA patients than migraine without aura(MWOA) group. However, no consistent results were observed according to our daily work. OBJECTIVE To investigate the prevalence and grade of RLS in migraine patients with and without aura and to evaluate the potential association between positive RLS and migraine with aura. METHODS A total of 91 migraine patients were involved, including 57 MWOA patients and 34 MA patients. MWOA and MA were diagnosed according to the International Classification of Headache Disorders, 3rd edition (beta version) (ICHD-3). Contrast transcranial Doppler ultra-sound (cTCD) was used to assess the prevalence of positive RLS, the associations between RLS and presence of aura. RESULTS The overall prevalence of RLS in migraine patients was 35.2%. In MA group, 44.1% (15/34) were positive for RLS overall, higher than MWOA group (29.8%,17/57). However, the differences were not significant (P = 0.167). And there were no marked differences in the prevalence of large, middle and small shunt between MA and MWOA patients. CONCLUSION Our study suggested MA patients have the slightly higher prevalence of positive RLS than MWOA patients in China. However, there were no significant differences, which was different from the previous studies. Our findings suggested the negative association between the positive RLS and migraine with aura.
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Affiliation(s)
- Yiyuan Xu
- Department of Function examination, Henan Provincial Hospital of Traditional Chinese Medicine, The Second Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou 450053, China.
| | - Rui Liu
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin 300052, China
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The Patent Foramen Ovale and Migraine: Associated Mechanisms and Perspectives from MRI Evidence. Brain Sci 2022; 12:brainsci12070941. [PMID: 35884747 PMCID: PMC9313384 DOI: 10.3390/brainsci12070941] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/10/2022] [Accepted: 07/15/2022] [Indexed: 02/04/2023] Open
Abstract
Migraine is a common neurological disease with a still-unclear etiology and pathogenesis. Patent foramen ovale (PFO) is a kind of congenital heart disease that leads to a right-to-left shunt (RLS). Although previous studies have shown that PFO has an effect on migraine, a clear conclusion about the link between PFO and migraine is lacking. We first summarized the PFO potential mechanisms associated with migraine, including microembolus-triggered cortical spreading depression (CSD), the vasoactive substance hypothesis, impaired cerebral autoregulation (CA), and a common genetic basis. Further, we analyzed the changes in brain structure and function in migraine patients and migraine patients with PFO. We found that in migraine patients with PFO, the presence of PFO may affect the structure of the cerebral cortex and the integrity of white matter, which is mainly locked in subcortical, deep white matter, and posterior circulation, and may lead to changes in brain function, such as cerebellum and colliculus, which are involved in the processing and transmission of pain. In summary, this paper provides neuroimaging evidence and new insights into the correlation between PFO and migraine, which will help to clarify the etiology and pathogenesis of migraine, and aid in the diagnosis and treatment of migraine in the future.
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Tang Y, Peng A, Peng B, He S, Zhao X, Zhu Y, Lai W, Song T, Chen L. Association between patent foramen ovale and migraine without aura: a community-based cross-sectional study in China. BMJ Open 2022; 12:e056937. [PMID: 35361647 PMCID: PMC8971771 DOI: 10.1136/bmjopen-2021-056937] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To assess the influence of patent foramen ovale (PFO) on the prevalence of migraine without aura based on propensity score-matched samples in Southwest China. DESIGN Propensity-matched cross-sectional study. PARTICIPANTS Residents over 20 years of age were recruited from 15 communities of Western China from July 2020 to October 2020. A total of 3741 residents having accepted to undergo contrast-transthoracic echocardiography and a standard structured questionnaire was assessed for the relationship between PFO and migraine without aura. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measures were the prevalence of migraine without aura across different degrees of right-left shunts. RESULTS A total of 3741 participants were included. Among them, 881 participants were diagnosed with PFO. The prevalence of migraine without aura in the PFO group was 12.83%, significantly higher than the other group (7.83%, p<0.0001). Analyses of the matched samples showed that the presence of a PFO increased the morbidity risk of migraine without aura (p < 0.001; OR=1.71, 95% CI 1.19 to 2.47). CONCLUSION This community-based cross-sectional study pointed to a strong association between PFO and migraine without aura, especially when the shunt is large. TRIAL REGISTRATION NUMBER ChiCTR1900024623.
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Affiliation(s)
- Yusha Tang
- Department of Neurology, Sichuan University West China Hospital, Chengdu, China
| | - Anjiao Peng
- Department of Neurology, Sichuan University West China Hospital, Chengdu, China
| | - Bo Peng
- Department of Ultrasonography, Mianzhu City People's Hospital, Mianzhu, China
| | - Shixu He
- Department of Neurology, Sichuan University West China Hospital, Chengdu, China
| | - Xia Zhao
- Department of Clinical Research Management, Sichuan University West China Hospital, Chengdu, China
| | - Yuanfeng Zhu
- Department of Clinical Research Management, Sichuan University West China Hospital, Chengdu, China
| | - Wanlin Lai
- Department of Neurology, Sichuan University West China Hospital, Chengdu, China
| | - Tingting Song
- Department of Neurology, Sichuan University West China Hospital, Chengdu, China
| | - Lei Chen
- Department of Neurology, Sichuan University West China Hospital, Chengdu, China
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Pristipino C, Germonpré P, Toni D, Sievert H, Meier B, D'Ascenzo F, Berti S, Onorato E, Bedogni F, Mas JL, Scacciatella P, Hildick-Smith D, Gaita F, Kyrle P, Thomson J, Derumeaux G, Sibbing D, Chessa M, Hornung M, Zamorano J, Dudek D. 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. EUROINTERVENTION 2021; 17:e367-e375. [PMID: 33506796 PMCID: PMC9724983 DOI: 10.4244/eij-d-20-00785] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Christian Pristipino
- San Filippo Neri - ASL Roma 1 Hospital, Via Alessandro Poerio 140, 00152 Rome, Italy
| | | | - Danilo Toni
- Hospital Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Horst Sievert
- CardioVascular Center Frankfurt (CVC Frankfurt), Frankfurt, Germany,Anglia Ruskin University, Chelmsford, United Kingdom,University California San Francisco (UCSF), San Francisco, CA, USA
| | | | - Fabrizio D'Ascenzo
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | | | | | | | - Jean-Louis Mas
- Hôpital Sainte-Anne, Université Paris Descartes, Paris, France
| | | | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Fiorenzo Gaita
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | | | | | | | - Dirk Sibbing
- Privatklinik Lauterbacher Mühle am Ostersee, Iffeldorf and Ludwig-Maximilians-Universität (LMU) München, Munich, Germany
| | - Massimo Chessa
- IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Marius Hornung
- CardioVascular Center Frankfurt (CVC Frankfurt), Frankfurt, Germany
| | | | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow, Poland,Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
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Relationship between non-headache symptoms and right to left shunt in episodic migraine. A single-center cross-sectional study. J Clin Neurosci 2021; 86:38-44. [PMID: 33775344 DOI: 10.1016/j.jocn.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 11/03/2020] [Accepted: 01/07/2021] [Indexed: 11/20/2022]
Abstract
The relationship between right to left shunt (RLS) and non-headache symptoms (NHS) in episodic migraine is unknown. This study aimed to investigate the incidence and classification of RLS in episodic migraineurs, calculate the occurrence rate of NHS, and analyze the associations between RLS and NHS. We consecutively recruited 204 episodic migraine patients. Contrast-enhanced transcranial doppler was adopted to screen RLS. Structured questionnaire via face-to-face survey was conducted to collect clinical data. A total of 172 episodic migraineurs were included in the final analysis, of which 20 cases were migraine with aura. The positive rate of RLS was 47.1%, of which 50 cases (29.0%) had small shunt (Grade 1) and 31 cases (18.1%) had mid-large shunt (Grade 2-4). The most common NHS was nausea (115 (66.9%)), followed by headache aggravation with physical activity (96 (55.8%)), dizziness (93 (54.1%)), vomiting (77 (44.8%)) and phonophobia (74 (43.0%)). Yawning was more common in Grade 2-4 group than Grade 0 group (p = 0.012), while no statistical differences among other groups. Grade 2-4 group had a higher rate of headache aggravation with physical activity than grade 0 group (p = 0.008). Binary logistic regression analysis showed that yawning at premonitory phase, headache aggravation with physical activity and cranial autonomic symptoms during attack are independent predictors of RLS. In conclusion, yawning and headache aggravation with physical activity are more common in migraine patients with RLS. Besides aura, particular NHS may also serve as indicators for screening RLS in episodic migraineurs.
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Mo X, Xuan Z, Zhang W, Wang W, Zhong J. Cardiac-Neurovascular Adverse Effects Responsible to Contrast Transcranial Doppler: A Case Report. J Stroke Cerebrovasc Dis 2020; 29:104627. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/19/2019] [Accepted: 12/22/2019] [Indexed: 10/25/2022] Open
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Han Y, Zhang X, Zhang F. Patent foramen ovale closure by using transesophageal echocardiography for cryptogenic stroke: single center experience in 132 consecutive patients. J Cardiothorac Surg 2020; 15:11. [PMID: 31918738 PMCID: PMC6953465 DOI: 10.1186/s13019-020-1042-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 01/02/2020] [Indexed: 01/23/2023] Open
Abstract
Background Percutaneous closure of patent foramen ovale (PFO) is routinely performed using plain fluoroscopy in the catheter room. This method results in inevitable radiation damage, adverse effects of contrast agents on kidneys, and high cost. We performed PFO closure with a simplified and economical transesophageal echocardiography (TEE)-only guided approach in the operating room. This study aimed to investigate the feasibility, safety, and effectiveness of the percutaneous closure of PFO by only using TEE. Methods We reviewed the medical records of patients who underwent percutaneous PFO closure at our center from December 2013 to December 2017. A total of 132 patients with PFO and cryptogenic strokes underwent PFO closure by using cardi-O-fix PFO device under TEE guidance. The participants comprised 64 and 68 male and female patients, respectively. The mean age and body weight of the patients were 39.40 ± 13.22 years old (12–68 years old) and 65.42 ± 9.70 kg (40–95 kg), respectively. All patients only received aspirin (3–5 mg/kg body weight, oral administration) for 6 months. Contrast-enhanced transthoracic echocardiography (c-TTE) with Valsalva maneuver was performed during follow-up, and questionnaire surveys were obtained at 3, 6, and 12 months after the procedure. Results All (100%) patients were successfully closed. Follow-ups were conducted for 13 months to 48 months, with an average of 27 months. No severe complications were found during the follow-up period. Paroxysmal atrial fibrillation occurred in 4 patients within 3 months after the procedure. No recurrent stroke or death occurred in all patients during the follow-up period. Transient ischemic attack occurred in one patient 6 months after the procedure. Ten (7.6%) patients had a right-to-left shunt, as demonstrated by c-TTE at 12 months of follow-up. Among the 57 patients suffering from migraine, significant relief or resolution was reported by 42 (73.7%) patients. Conclusion TEE-only guided PFO closure was a safe, feasible, and effective method that did not require the use of X-rays and contrast agents.
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Affiliation(s)
- Yangyang Han
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, West Wenhua Road No.107, Lixia District, Jinan, 250012, Shandong Province, China.,Department of Cardiovascular Surgery, Linyi People's Hospital Affiliated to Shandong University, Jiefang Street No. 27, Linyi, 276000, Shandong Province, China
| | - Xiquan Zhang
- Department of Cardiovascular Surgery, Linyi People's Hospital Affiliated to Shandong University, Jiefang Street No. 27, Linyi, 276000, Shandong Province, China.
| | - Fengwei Zhang
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, West Wenhua Road No.107, Lixia District, Jinan, 250012, Shandong Province, China
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Chen D, Willis-Parker M, Lundberg GP. Migraine headache: Is it only a neurological disorder? Links between migraine and cardiovascular disorders. Trends Cardiovasc Med 2019; 30:424-430. [PMID: 31679956 DOI: 10.1016/j.tcm.2019.10.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 10/19/2019] [Accepted: 10/19/2019] [Indexed: 12/22/2022]
Abstract
Migraine headache (MH) is a common disorder affecting millions of people in the United States. MH is substantially more prevalent in women compared to men. An association between migraine with or without aura and risk of cardiovascular disease (CVD) has been extensively reported. There are several proposed theories that may explain the pathophysiologic relationship between MH and CVD. This review will summarize the recent literature on this topic and provide an evidence-based perspective regarding the current knowledge and controversies regarding association of MH and CVD.
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Affiliation(s)
- Dandan Chen
- Department of Medicine, Division of Cardiology, Emory University, Atlanta, GA 30322, United States
| | | | - Gina Price Lundberg
- Department of Medicine, Division of Cardiology, Emory University, Atlanta, GA 30322, United States; Emory Women's Heart Center, Department of Medicine, Division of Cardiology, Emory University, Atlanta, GA 30322, United States.
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He Q, Zhang Y, Wang F, Li C, Guo R, Li X, Luan B, Zhao H, Meng L, Chen H, Meng L. Impact of right-to-left shunt and transcatheter closure on the clinical features of migraine. Int J Neurosci 2019; 130:270-275. [PMID: 31549584 DOI: 10.1080/00207454.2019.1672681] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Objectives: In this study, we aimed to explore the influence of right-to-left shunt (RLS) presence on the clinical features of migraine and to follow-up on the post-operative curative effect of transcatheter patent foramen ovale (PFO) closure on migraine features.Methods: A total of 103 migraine patients were divided into a mild volume RLS group, moderate volume RLS group, large volume RLS group and non-RLS group in accordance with contrast enhancement transcranial Doppler (c-TCD) findings. The Visual Analogue Scale (VAS) score, migraine frequency, migraine duration, migraine disability assessment (MIDAS) and headache impact test-6 (HIT-6) scores were compared amongst the different groups. A total of 39 patients with moderate or large RLS received transcatheter PFO closure and those patients were followed up by the same criteria.Results: The attack frequency, HIT-6 and MIDAS scores amongst the migraine patients with moderate or large RLS were significantly higher than those in patients from the mild RLS group and non-RLS group (p < .05). The transcatheter closure was successful in all patients (n = 39), and no post-operative complications were observed during the hospitalisation and follow-up period. The differences in VAS, HIT-6 and MIDAS scores as well as the headache duration were statistically significant amongst patients before and after PFO closure (p < .05).Conclusions: Moderate to large RLS significantly influenced the clinical features of migraine, and transcatheter PFO closure could significantly relieve headache symptoms in migraine patients with PFO.
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Affiliation(s)
- Qiu He
- Department of Neurology, The People's Hospital of Liaoning Province, Shenyang, China
| | - Yingbin Zhang
- Nerve Rehabilitation Center, Beijing Rehabilitation Hospital Affiliated to Capital Medical University, Beijing, China
| | - Fengzhi Wang
- Department of Neurology, The People's Hospital of Liaoning Province, Shenyang, China
| | - Chao Li
- Department of Neurology, The People's Hospital of China, Three Gorges University, YiChang, China
| | - Rong Guo
- Department of Neurology Function, The People's Hospital of Liaoning Province, Shenyang, China
| | - Xiangnan Li
- Department of Neurology Function, The People's Hospital of Liaoning Province, Shenyang, China
| | - Bo Luan
- Department of Cardiovascular Medicine, The People's Hospital of Liaoning Province, Shenyang, China
| | - Hongwei Zhao
- Department of Cardiovascular Medicine, The People's Hospital of Liaoning Province, Shenyang, China
| | - Lili Meng
- Department of Congenital Heart Disease, The General Hospital of Shenyang Military Region, Shenyang, China
| | - Huisheng Chen
- Department of Neurology, The General Hospital of Shenyang Military Region, Shenyang, China
| | - Li Meng
- Graduate School of Dalian Medical University, Dalian, China
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Liu Y, Li S, Wang R, Han X, Su M, Cao X, Wang G, Cao F, Yu S. A New Perspective of Migraine Symptoms in Patients With Congenital Heart Defect. Headache 2018; 58:1601-1611. [PMID: 30444273 DOI: 10.1111/head.13453] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2018] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Yinglu Liu
- Department of Neurology, Chinese PLA General Hospital, Beijing, China
| | - Sulei Li
- Department of Cardiology & National Clinical Research Center of Geriatric Disease, Chinese PLA General Hospital, Beijing, China
| | - Rongfei Wang
- Department of Neurology, Chinese PLA General Hospital, Beijing, China
| | - Xun Han
- Department of Neurology, Chinese PLA General Hospital, Beijing, China
| | - Min Su
- Department of Neurology, Chinese PLA General Hospital, Beijing, China
| | - Xiutang Cao
- Department of Medical Statistics, Chinese PLA General Hospital, Beijing, China
| | - Guangyi Wang
- Department of Cardiology & National Clinical Research Center of Geriatric Disease, Chinese PLA General Hospital, Beijing, China
| | - Feng Cao
- Department of Cardiology & National Clinical Research Center of Geriatric Disease, Chinese PLA General Hospital, Beijing, China
| | - Shengyuan Yu
- Department of Neurology, Chinese PLA General Hospital, Beijing, China
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Zhang Y, Parikh A, Qian S. Migraine and stroke. Stroke Vasc Neurol 2017; 2:160-167. [PMID: 28989805 PMCID: PMC5628377 DOI: 10.1136/svn-2017-000077] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/06/2017] [Accepted: 04/09/2017] [Indexed: 12/23/2022] Open
Abstract
Migraines are generally considered a relatively benign neurological condition. However, research has shown an association between migraines and stroke, and especially between migraine with aura and ischaemic stroke. Patients can also suffer from migrainous infarction, a subset of ischaemic stroke that often occurs in the posterior circulation of younger women. The exact pathogenesis of migrainous infarct is not known, but it is theorised that the duration and local neuronal energy level from cortical spreading depression may be a key factor. Other factors contributing to migrainous infarct may include vascular, inflammatory, endothelial structure, patent foramen ovale, gender, oral contraceptive pill use and smoking. Vasoconstrictors such as the triptan and ergot class are commonly used to treat migraines and may also play a role. Migraine is also shown to be correlated to haemorrhagic stroke, although studies do not demonstrate causation versus association, and further studies are warranted. There are also some rare genetic diseases such as cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy, retinal vasculopathy with cerebral leukodystrophy and others, which can cause both migraines and infarcts. On imaging, many migraineurs are found to have white matter changes similar to those seen in patients with stroke. These may be caused in part by alterations in resting cerebral blood flow and vasoconstrictor use. In treating patients with migraines, it is important to identify and modify any vascular risk factors such as hypertension, smoking, oral contraceptive pill use and lifestyle factors. Further studies will determine if more aggressive treatment of migraines can ultimately lead to fewer strokes in this population.
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Affiliation(s)
- Yonghua Zhang
- Edward Neurosciences Institute in affiliation with Northwestern Medicine, Naperville, Illinois, USA
| | - Aasheeta Parikh
- Edward Neurosciences Institute in affiliation with Northwestern Medicine, Naperville, Illinois, USA
| | - Shuo Qian
- Department of Neurology & Rehabilitation, University of Illinois, Chicago, Illinois, USA
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Abstract
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.
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Abstract
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.
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Affiliation(s)
- Melissa Rayhill
- Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, NY, USA
| | - Rebecca Burch
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. .,John R. Graham Headache Center, 1153 Centre Street Suite 4970, Jamaica Plain, Boston, MA, 02130, USA.
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16
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Wang SB, Liu KD, Yang Y, Li YJ, Hu MY, Lin P, Guo R, Tian Q, You Y, Cui YH, Zhang GL, Dong Z, Gao YS, Xing YQ. Prevalence and extent of right-to-left shunt on contrast-enhanced transcranial Doppler in Chinese patients with migraine in a multicentre case-control study. Cephalalgia 2017; 38:690-696. [PMID: 28474985 DOI: 10.1177/0333102417708203] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The association between RLS and migraine is still debated. The aim of this study is to investigate the prevalence and grade of RLS in Chinese patients with migraine and to evaluate the relationship between RLS and migraine. Methods A multi-center case-control study of contrast-enhanced transcranial Doppler was conducted in 931 consecutive patients with migraine (240 of 931 had migraine with aura and 691 of 931 were in the migraine without aura group) and 282 were healthy adults. Clinical trial no. NCT02425696. Results The prevalence of RLS was 63.8% and 39.9% in the migraine with aura group (MA+) and migraine without aura group (MA−), respectively, significantly higher than that of the healthy group (29.4%, p < 0.001; p < 0.001). The positive rate of large RLS in the MA+ group and MA− group was 32.1% and 16.5%, respectively, significantly higher than healthy group (6.4%, p < 0.001; p < 0.001). There was no difference among groups in terms of positive rate of permanent RLS ( p = 0.704). Conclusion This multi-centre case-control study suggested that there is an association between RLS and migraine with and without aura, especially when the shunt is large.
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Affiliation(s)
- Si-Bo Wang
- Neuroscience Centre, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Kang-Ding Liu
- Neuroscience Centre, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Yi Yang
- Neuroscience Centre, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Ya-Jie Li
- Diagnostic Ultrasound Centre, The Centre Hospital of Jilin City, Jilin, China
| | - Ming-Yi Hu
- Department of Neurology, Weifang People’s Hospital, Weifang, China
| | - Pan Lin
- Department of Neurology, The Second Hospital of Longyan City, Longyan, China
| | - Rong Guo
- Department of Neurology Function, The People’s Hospital of Liaoning Province, Shenyang, China
| | - Qian Tian
- Department of Neurology, People’s Hospital of Linyi city, Linyi, China
| | - Yong You
- Department of Neurology, The First Hospital of University of South China, Hengyang, China
| | - Ying-Hua Cui
- Centre of Head and Neck Vascular Ultrasound, Department of Neurology, The Hospital of Yanbian University, Yanji, China
| | - Guan-Ling Zhang
- Department of Ultrasound, The Centre Hospital of Changsha City, Changsha, China
| | - Zhao Dong
- Department of Neurology, Chinese PLA General Hospital, Beijing, China
| | - Yong-Sheng Gao
- Department of Cardiac Surgery, The First Hospital of Jilin University, Changchun, China
| | - Ying-Qi Xing
- Neuroscience Centre, Department of Neurology, The First Hospital of Jilin University, Changchun, China
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17
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Xing YQ, Guo YZ, Gao YS, Guo ZN, Niu PP, Yang Y. Effectiveness and Safety of Transcatheter Patent Foramen Ovale Closure for Migraine (EASTFORM) Trial. Sci Rep 2016; 6:39081. [PMID: 27966652 PMCID: PMC5155423 DOI: 10.1038/srep39081] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 11/17/2016] [Indexed: 01/03/2023] Open
Abstract
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).
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Affiliation(s)
- Ying-Qi Xing
- Department of Neurology and Neuroscience Center, the First Hospital of Jilin University, Changchun, China
| | - Yu-Zhu Guo
- Department of Neurology and Neuroscience Center, the First Hospital of Jilin University, Changchun, China.,Department of Neurology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Yong-Sheng Gao
- Department of Cardiac Surgery, the First Hospital of Jilin University, Changchun, China
| | - Zhen-Ni Guo
- Department of Neurology and Neuroscience Center, the First Hospital of Jilin University, Changchun, China
| | - Peng-Peng Niu
- Department of Neurology and Neuroscience Center, the First Hospital of Jilin University, Changchun, China
| | - Yi Yang
- Department of Neurology and Neuroscience Center, the First Hospital of Jilin University, Changchun, China
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Larrosa D, Ramón C, Alvarez R, Martínez-Camblor P, Cernuda E, Pascual J. No Relationship Between Patent Foramen Ovale and Migraine Frequency. Headache 2016; 56:1466-1473. [PMID: 27634435 DOI: 10.1111/head.12945] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2016] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Davinia Larrosa
- Service of Neurology, University Hospital "Central de Asturias" and INEUROPA, Oviedo, Spain.
| | - César Ramón
- Service of Neurology, University Hospital "Central de Asturias" and INEUROPA, Oviedo, Spain
| | - Rocío Alvarez
- Service of Neurology, University Hospital "Central de Asturias" and INEUROPA, Oviedo, Spain
| | - Pablo Martínez-Camblor
- Geisel School of Medicine at Darmouth, Hanover, NH, USA.,Autonomous University of Chile, Santiago, Chile
| | - Eva Cernuda
- Service of Neurology, University Hospital "Central de Asturias" and INEUROPA, Oviedo, Spain.,Geisel School of Medicine at Darmouth, Hanover, NH, USA
| | - Julio Pascual
- Service of Neurology, University Hospital "Central de Asturias" and INEUROPA, Oviedo, Spain.,University Hospital "Marqués de Valdecilla" and IDIVAL, Santander, España
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Mitsikostas DD, Ashina M, Craven A, Diener HC, Goadsby PJ, Ferrari MD, Lampl C, Paemeleire K, Pascual J, Siva A, Olesen J, Osipova V, Martelletti P. European Headache Federation consensus on technical investigation for primary headache disorders. J Headache Pain 2016; 17:5. [PMID: 26857820 PMCID: PMC4747925 DOI: 10.1186/s10194-016-0596-y] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 02/02/2016] [Indexed: 01/03/2023] Open
Abstract
The diagnosis of primary headache disorders is clinical and based on the diagnostic criteria of the International Headache Society (ICHD-3-beta). However several brain conditions may mimic primary headache disorders and laboratory investigation may be needed. This necessity occurs when the treating physician doubts for the primary origin of headache. Features that represent a warning for a possible underlying disorder causing the headache are new onset headache, change in previously stable headache pattern, headache that abruptly reaches the peak level, headache that changes with posture, headache awakening the patient, or precipitated by physical activity or Valsalva manoeuvre, first onset of headache ≥50 years of age, neurological symptoms or signs, trauma, fever, seizures, history of malignancy, history of HIV or active infections, and prior history of stroke or intracranial bleeding. All national headache societies and the European Headache Alliance invited to review and comment the consensus before the final draft. The consensus recommends brain MRI for the case of migraine with aura that persists on one side or in brainstem aura. Persistent aura without infarction and migrainous infarction require brain MRI, MRA and MRV. Brain MRI with detailed study of the pituitary area and cavernous sinus, is recommended for all TACs. For primary cough headache, exercise headache, headache associated with sexual activity, thunderclap headache and hypnic headache apart from brain MRI additional tests may be required. Because there is little and no good evidence the committee constructed a consensus based on the opinion of experts, and should be treated as imperfect.
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Affiliation(s)
- D D Mitsikostas
- Neurology Department, Athens Naval Hospital, Athens, Greece.
| | - M Ashina
- Danish Headache Center, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - A Craven
- European Headache Alliance, President, Dublin, Ireland.
| | - H C Diener
- Department of Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
| | - P J Goadsby
- Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, and King's Clinical Research Facility, Kings College London, Wellcome Foundation Building, King's College Hospital, London, SE5 9PJ, UK.
| | - M D Ferrari
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - C Lampl
- Medical Headache Center, Hospital Sisters of Mercy, Seilerstaette Linz, Linz, 4020, Austria.
| | - K Paemeleire
- Department of Neurology, Ghent University Hospital, Ghent, Belgium.
| | - J Pascual
- University Hospital Marqués de Valdecilla and IDIVAL, 39011, Santander, Spain.
| | - A Siva
- Department of Neurology, Cerrahpasa School of Medicine, Istanbul University, Millet Cad, 34390, Capa/Istanbul, Turkey.
| | - J Olesen
- Danish Headache Centre and Department of Neurology, Rigshospitalet, Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - V Osipova
- Department of Neurology, First Moscow State Medical University, Moscow, Russia.
| | - P Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.
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Eren NK, Nazlı C. Are Right to Left Shunts Underdiagnosed in the Etiology of Migraine Headache? --A Response. Headache 2015; 55:1270-1. [PMID: 26382211 DOI: 10.1111/head.12691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Nihan K Eren
- Cardiology Department, Izmir Katip Celebi University Ataturk Education and Research Hospital, Izmir, Turkey
| | - Cem Nazlı
- Cardiology Department, Izmir Katip Celebi University Ataturk Education and Research Hospital, Izmir, Turkey
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21
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Aparci M, Isilak Z, Kendirli MT, Yalcin M. Are Right to Left Shunts Underdiagnosed in the Etiology of Migraine Headache? Headache 2015; 55:1268-9. [DOI: 10.1111/head.12692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Mustafa Aparci
- Department of Cardiology and Aviation Examination Center; Kasimpasa Military Hospital; Istanbul Turkey
| | - Zafer Isilak
- Department of Cardiology; Haydarpasa Training Hospital; Istanbul Turkey
| | | | - Murat Yalcin
- Department of Cardiology; Haydarpasa Training Hospital; Istanbul Turkey
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