Patent Foramen Ovale and Migraine: A Quantitative Systematic Review

Patent Foramen Ovale and Atrial Septal Defect

Patent foramen ovale (PFO) and atrial septal defects (ASDs) are two types of interatrial communications with unique clinical presentations and management strategies. The PFO is a normal part of fetal development that typically closes shortly after birth but may persist in as many as 25% to 30% of adults. The communication between atria may result in paradoxic embolism and embolic stroke. On the other hand, ASDs (anatomically defined as secundum, primum, sinus venosus, and coronary sinus in order of prevalence) typically result in right heart volume overload and are often associated with other congenital defects. The diagnostic methods, treatment options including surgical and percutaneous approaches, and potential complications are described. Both conditions underline the significance of precise diagnosis and appropriate management to mitigate risks and ensure optimal patient outcomes.

Headache patterns in patent foramen ovale patients: beyond migraine with aura

Patent foramen ovale (PFO) is a common cardiac anomaly linked with cryptogenic strokes and migraine, particularly migraine with aura. This study aims to explore the spectrum of headache disorders in PFO patients, focusing on identifying patterns beyond the well-established migraine-PFO connection. A retrospective observational study was conducted on patients diagnosed with PFO. Headache types were classified using the International Classification of Headache Disorders, 3rd edition. The study analyzed headache prevalence and patterns in PFO patients, comparing those with and without a history of stroke. Of 177 participants, 63 (35.59%) reported headaches. Tension-type headache was the most common (15.25%), followed by migraine without aura (11.30%) and migraine with aura (8.47%). Notably, migraine without aura was more prevalent than migraine with aura, contrasting previous assumptions. No significant differences were found in headache types based on stroke history. The study reveals a diverse spectrum of headache types in PFO patients, with migraine without aura being more common than migraine with aura. These findings suggest a need for broader diagnostic perspective and individualized treatment approaches in PFO patients with headaches.

Every Patent Foramen Ovale Should Be Closed

At present, the patent foramen ovale (PFO) does not receive the deserved medical attention. The PFO poses a serious threat to health and even the life of mankind. The first respective case report in the medical literature dates back to the 19th century. It led to death. The fact that a PFO is present in roughly 25% of people underscores its overall potential to cause harm. Yet at the same time, the sheer number discourages the medical community from screening for it and from treating it. About 5% of the population have particularly dangerous forms of PFOs. Such PFOs portray a high enough risk for clinical events, the likes of death, stroke, myocardial infarction, or ocular, visceral, and peripheral embolism, to justify screening for them. Highly significant health incidents being at stake, it appears obvious that PFO closure should be used for primary prevention. This is supported by the fact that closing a PFO is the simplest intervention in cardiology, with presumably the highest clinical yield. Being mainly a preventive measure, PFO closure represents a mechanical vaccination. When closing PFOs for one of the rarer therapeutic indications (migraine, platypnea orthodeoxia, etc.), patients automatically profit from the collateral benefit of getting, at the same time, mechanically vaccinated for life against paradoxical embolism. Vice versa, closing a PFO for the prevention of paradoxical embolism betters or cures migraine or exercise dyspnea not infrequently, thereby improving quality of life as a collateral benefit.

Headache due to Vascular Disorders

Headache and cerebrovascular disease (CVD) are inextricably linked. Although in some cases headache complicating CVD may be little more than a symptomatic afterthought, in other cases, early recognition of headache's role in the CVD process is critical to effective management. In other words, headaches secondary to CVD span a spectrum, and in this article, we will review that spectrum.

Approval, Evidence, and "Off-Label" Device Utilization: The Patent Foramen Ovale Closure Story

BACKGROUND

Following regulatory approval, medical devices may be used "off-label." Patent foramen ovale (PFO) closure is indicated to reduce recurrent stroke but has been proposed for other indications, including migraine, transient ischemic attack, and diving decompression illness. We sought to evaluate PFO closure rates and indications relative to the timing of regulatory approval and publication of key randomized trials.

METHODS

We performed a retrospective cohort study using the OptumLabs Data Warehouse of US commercial insurance enrollees from 2006 to 2019. We quantified PFO closure among individuals with ≥2 years of preprocedure coverage to establish indications, classified hierarchically as stroke/systemic embolism, migraine, transient ischemia attack, or other.

RESULTS

We identified 5315 patients undergoing PFO closure (51.8% female, 29.2%≥60 years old), which increased from 4.75 per 100 000 person-years in 2006 to 6.60 per 100 000 person-years in 2019. Patients aged ≥60 years accounted for 29.2% of closures. Procedure volumes corresponded weakly with supportive clinical publications and device approval. Among patients with PFO closure, 58.6% underwent closure for stroke/systemic embolism, 10.2% for transient ischemia attack, 8.8% for migraine, and 22.4% for other indications; 17.6% of patients had atrial fibrillation at baseline; and 11.9% developed atrial fibrillation postprocedure. Those aged ≥60 years and male were less likely to undergo closure for migraine than stroke/systemic embolism.

CONCLUSIONS

From 2006 to 2019, PFO closure use was consistently low and corresponded weakly with clinical trial publications and regulatory status. Nearly half of patients underwent PFO closure for indications unapproved by the Food and Drug Administration. Regulators and payers should coordinate mechanisms to promote utilization for approved indications to ensure patient safety and should facilitate clinical trials for other possible indications.

Bibliometric Analysis of Research on Migraine-Stroke Association from 2013 to 2023

Background

Both migraine and stroke heavily burden individuals, health systems, and society. The migraine-stroke association is of concern and has been studied widely. Our objective is to explore and overview the current research status and emerging trends.

Materials and Methods

Studies on migraine-stroke association from January 2013 to May 2023 were retrieved and screened from the Web of Science Core Collection (WOSCC) database. Records fulfilling the selection criteria were downloaded and imported into CiteSpace for data mining and visualization.

Results

A total of 862 papers on migraine-stroke association were included. Annual publications grew slowly. The United States and European countries dominated research in this area. Harvard University published the largest number of articles, while the University of London was most active with other institutions. Ayata Cenk contributed the most articles, while KURTH T and NEUROLOGY were co-cited most. Research hotspots included migraine with aura, ischemic stroke, patent foramen ovale, cortical spreading depolarization, meta-analysis, cross-sectional study, and risk factors. Pathophysiology and small vessel disease represented research frontiers and emerging trends.

Conclusion

Our study scientifically outlines the migraine-stroke association over the past decade, presenting useful information.

The prevalence of positive right to left shunt in migraine patients with and without aura: A new single-center study in China

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.

Clinical Outcomes and Quality of Life after Patent Foramen Ovale (PFO) Closure in Patients with Stroke/Transient Ischemic Attack of Undetermined Cause and Other PFO-Associated Clinical Conditions: A Single-Center Experience

INTRODUCTION

The aim of this study was to assess clinical outcomes and quality of life after PFO closure in patients with previous stroke/TIA of undetermined cause and in patients with other complex PFO-associated clinical conditions.

METHODS

Between July 2009 and December 2019 at our University Cardiology Department, 118 consecutive patients underwent a thorough diagnostic work-up including standardized history taking, clinical evaluation, full neurological examination, screening for thrombophilia, brain magnetic resonance imaging (MRI), ultrasound-Doppler sonography of supra-aortic vessels and 24 h ECG Holter monitoring. Anatomo-morphological evaluation using 2D transthoracic/transesophageal echocardiography (TTE/TEE) color Doppler and functional assessment using contrast TTE (cTTE) in the apical four-chamber view and contrast transcranial Doppler (cTCD) using power M-mode modality were performed to verify the presence, location and amount of right-to-left shunting via PFO or other extracardiac source. Completed questionnaires based on the Quality-of-Life Short Form-36 (QoL SF-36) and Migraine Disability Assessment (MIDAS) were obtained from the patients before PFO closure and after 12 months. Contrast TTE/TEE and cTCD were performed at dismission, 1, 6 and 12 months and yearly thereafter. Brain MRI was performed at 1-year follow-up in 54 patients.

RESULTS

Transcatheter PFO closure was performed in 106 selected symptomatic patients (mean age 41.7 ± 10.7 years, range 16-63, 65% women) with the following conditions: ischemic stroke (n = 23), transient ischemic attack (n = 22), peripheral and coronary embolism (n = 2), MRI lesions without cerebrovascular clinical events (n = 53), platypnea-orthodeoxia (n = 1), decompression sickness (n = 1) and refractory migraine without ischemic cerebral lesions (n = 4). The implanted devices were Occlutech Figulla Flex I/II PFO (n = 99), Occlutech UNI (n = 3), Amplatzer PFO (n = 3) and CeraFlex PFO occluders (n = 1). Procedures were performed under local anesthesia and rotational intracardiac monitoring (Ultra ICE) alone. The devices were correctly implanted in all patients. The mean fluoroscopy time was 15 ± 5 min (range = 10-45 min) and the mean procedural time was 55 ± 20 min (range = 35-90 min). The total occlusion rate at follow-up (mean 50 months, range 3-100) was 98.1%. No recurrent neurological events were observed in the long-term follow-up.

CONCLUSIONS

The data collected in this study demonstrate that percutaneous PFO closure is a safe and effective procedure, showing long-term prevention of recurrent cerebrovascular events, significant reduction in migraine symptoms and substantial improvement in quality of life.

A higher probability of subsequent stroke and ischemic heart disease in migraine patients: a longitudinal follow-up study in Korea

BACKGROUND

Whether migraine is related to the risk of cardiovascular diseases (CVDs) remains unclear. Therefore, we conducted a longitudinal follow-up study to address the association between migraine and the development of CVDs in Korea.

METHODS

Using data from the national health screening cohort, we included 45,246 patients diagnosed with migraine between 2002 and 2019 and age-, sex-, income-, and residential region-matched nonmigraine participants at a ratio of 1:4. Participants with previous CVDs were excluded. Cox proportional hazards regression models were used to estimate the hazard ratios of three CVDs, stroke, ischemic heart disease, and heart failure, in patients with migraine after adjusting for potential cardiovascular risk factors.

RESULTS

The incidence rate differences of stroke, ischemic heart disease, and heart failure among patients with migraine were 2.61, 1.69, and 0.11, respectively. The probability of developing stroke and ischemic heart disease in patients with migraine was significantly higher than that in controls after controlling for multiple confounders (adjusted hazard ratio [HR] = 1.35, 95% confidence interval [CI] = 1.31-1.39 and adjusted HR = 1.31, 95% CI = 1.26-1.35, respectively). However, when compared with the patients without migraine, patients with migraine did not have an increased HR of developing heart failure (adjusted HR = 1.01, 95% CI = 0.95-1.08). The overall migraine group, as well as groups stratified by migraine subtypes with and without aura, each showed a significantly higher probability of subsequent stroke and ischemic heart disease than the control group.

CONCLUSIONS

Our longitudinal follow-up study demonstrated a significant association between the presence of migraine and the development of stroke and ischemic heart disease in Korea, even after adjusting for cardiovascular risk factors.

Advances in Management of the Stroke Etiology One-Percenters

PURPOSE OF REVIEW

Uncommon causes of stroke merit specific attention; when clinicians have less common etiologies of stoke in mind, the diagnosis may come more easily. This is key, as optimal management will in many cases differs significantly from "standard" care.

RECENT FINDINGS

Randomized controlled trials (RCT) on the best medical therapy in the treatment of cervical artery dissection (CeAD) have demonstrated low rates of ischemia with both antiplatelet and vitamin K antagonism. RCT evidence supports the use of anticoagulation with vitamin K antagonism in "high-risk" patients with antiphospholipid antibody syndrome (APLAS), and there is new evidence supporting the utilization of direct oral anticoagulation in malignancy-associated thrombosis. Migraine with aura has been more conclusively linked not only with increased risk of ischemic and hemorrhagic stroke, but also with cardiovascular mortality. Recent literature has surprisingly not provided support the utilization of L-arginine in the treatment of patients with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS); however, there is evidence at this time that support use of enzyme replacement in patients with Fabry disease. Additional triggers for reversible cerebral vasoconstriction syndrome (RCVS) have been identified, such as capsaicin. Imaging of cerebral blood vessel walls utilizing contrast-enhanced MRA is an emerging modality that may ultimately prove to be very useful in the evaluation of patients with uncommon causes of stroke. A plethora of associations between cerebrovascular disease and COVID-19 have been described. Where pertinent, authors provide additional tips and guidance. Less commonly encountered conditions with updates in diagnosis, and management along with clinical tips are reviewed.

Recent progress in patent foramen ovale and related neurological diseases: A narrative review

Patent foramen ovale (PFO) is a common congenital cardiac abnormality when the opening of the interatrial septum is not closed in adulthood. This abnormality affects 25% of the general population. With the development of precision medicine, an increasing number of clinical studies have reported that PFO is closely related to various neurological diseases such as stroke, migraine, obstructive sleep apnea, and decompression syndrome. It has also been suggested that PFO closure could be effective for preventing and treating these neurological diseases. Therefore, increasing attention has been given to the prevention, diagnosis, and treatment of PFO-related neurological diseases. By reviewing existing literature, this article focuses on the pathogenesis, epidemiology, and clinical characteristics of PFO-related neurological diseases, as well as the prevention and treatment of different neurological diseases to discuss, and aims to provide current progress for this field and decision-making evidence for clinical practice.

Connection between right-to-left shunt and photosensitivity: a community-based cross-sectional study

Background

Hypersensitivity to light is a common symptom associated with dysfunction of the occipital region. Earlier studies also suggested that clinically significant right-to-left shunt (RLS) could increase occipital cortical excitability associated with the occurrence of migraine. The aim of this study was to investigate the relationship between RLS and photosensitivity.

Methods

This cross-sectional observational study included the residents aged 18-55 years living in the Mianzhu community between November 2021 and October 2022. Photosensitivity was evaluated using the Photosensitivity Assessment Questionnaire along with baseline clinical data through face-to-face interviews. After the interviews, contrast-transthoracic echocardiography (cTTE) was performed to detect RLS. Inverse probability weighting (IPW) was used to reduce selection bias. Photosensitivity score was compared between individuals with and without significant RLS using multivariable linear regression based on IPW.

Results

A total of 829 participants containing 759 healthy controls and 70 migraineurs were finally included in the analysis. Multivariable linear regression analysis showed that migraine (β = 0.422; 95% CI: 0.086-0.759; p = 0.014) and clinically significant RLS (β = 1.115; 95% CI: 0.760-1.470; p < 0.001) were related to higher photosensitivity score. Subgroup analysis revealed that clinically significant RLS had a positive effect on hypersensitivity to light in the healthy population (β = 0.763; 95% CI: 0.332-1.195; p < 0.001) or migraineurs (β = 1.459; 95% CI: 0.271-2.647; p = 0.010). There was also a significant interaction between RLS and migraine for the association with photophobia (p_interaction = 0.009).

Conclusion

RLS is associated with photosensitivity independently and might exacerbate photophobia in migraineurs. Future studies with RLS closure are needed to validate the findings.

Trial registration

This study was registered at the Chinese Clinical Trial Register, Natural Population Cohort Study of West China Hospital of Sichuan University, ID: ChiCTR1900024623, URL: https://www.chictr.org.cn/showproj.html?proj=40590.

Different effects of air microembolism through patent foramen ovale in patients with migraine: A quantitative electroencephalogram case series

Background

Literature suggests an association between patent foramen ovale (PFO) and migraine, mostly migraine with aura (MA). Previous data suggest that air microembolism through PFO can lead to bioelectrical abnormalities detectable at electroencephalogram (EEG) in patients with MA, thus suggesting a pathophysiological mechanism for the MA-PFO association. However, those data lack replication.

Methods

Patients with MA or migraine without aura (MO) and large PFO underwent a 19-channel EEG recording before and after injection of air microbubbles. We compared EEG power before and after microbubble injection for each electrode location, for each frequency band (theta: 5-7 Hz; alpha: 8-12 Hz; beta: 13-30 Hz; lower gamma: 31-45 Hz), and for total global power (the average of EEG power at each location and frequency band).

Results

We included 10 patients, four with MA and six with MO; six patients had medium-to-high migraine frequency (four or more monthly migraine days), while four had low frequency (one monthly migraine day). EEG power changes after air microembolism varied across patients. Considering the overall group, total global EEG power did not change; however, EEG power in the higher frequency ranges (beta and lower gamma) increased in patients with MA.

Conclusions

We did not replicate the effects of air microembolism previously reported in patients with migraine. Aura status, migraine frequency, and medications might influence patients' response to microembolism. More refined EEG measurements are needed to clarify the dynamic role of PFO on migraine occurrence.

Patent foramen ovale: diagnostic evaluation and the role of device closure

Although seemingly benign, the presence of a patent foramen ovale (PFO) may play an important role in the pathophysiology of disease, specifically a paradoxical embolism leading to cryptogenic stroke. The European Society of Cardiology recently published guidelines detailing how PFOs are associated with paradoxical embolism and how they are diagnosed and managed. This review guides physicians in the diagnostic and referral process to a multidisciplinary team involved in PFO closure. It reviews the clinical trials comparing device closure with medical therapy and highlights the current NHS England commissioning process on PFO management. Finally, we give an overview of other conditions where PFO device closure may need to be considered.

Migraine in Patients Undergoing PFO Closure

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Patients experiencing MHA-PFO on aspirin are characterized by a marked thrombin generation capacity sustained by an elevated number of platelets and MVs expressing a functionally active tissue factor.

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MHA-PFO patients are also characterized by an altered oxidative stress status, ie, increased platelet ROS production and blood GSSG/GSH ratio.

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This prothrombotic condition fully reverts upon PFO closure and is associated with 100% migraine remission.

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MHA-PFO plasma and GSSG, added to blood of healthy subjects, mirrored the in vivo platelet activation and this effect is blunted by N-acetylcysteine, thus supporting the etiopathogenetic role of oxidative stress in this clinical setting.

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Aspirin had little effect on the platelet prothrombotic phenotype that was better controlled by P2Y₁₂ antagonist.

The association between migraine and patent foramen ovale (PFO) has been documented. We aimed to investigate platelet activation, prothrombotic phenotype, and oxidative stress status of migraineurs with PFO on 100 mg/day aspirin, before and 6 months after PFO closure. Data show that, before PFO closure, expression of the classical platelet activation markers is comparable in patients and aspirin-treated healthy subjects. Conversely, MHA-PFO patients display an increased prothrombotic phenotype (higher tissue factor^pos platelets and microvesicles and thrombin-generation potential), sustained by an altered oxidative stress status. This phenotype, which is more controlled by P2Y₁₂-blockade than by aspirin, reverted after PFO closure together with a complete migraine remission. (pLatelEts And MigRaine iN patEnt foRamen Ovale [LEARNER]; NCT03521193)

Patent Foramen Ovale Closure for Treating Migraine: A Meta-Analysis

Background

Observational studies have shown percutaneous patent foramen ovale (PFO) closure to be a safe means of reducing the frequency and duration of migraine.

Objective

This study evaluated the efficacy and safety of PFO closure in patients with migraine using evidence-based medicine.

Methods

The Pubmed (MEDLINE), Embase, and Cochrane Library databases were searched for randomized controlled trials (RCTs), cohort studies, and retrospective case series from January 1, 2001, to February 30, 2021. The Jadad scale and R 4.1.0 software were used to assess the quality of the literature and meta-analysis, respectively.

Results

In total, three randomized controlled trials, one pooled study, and eight retrospective case series including 1,165 participants were included in the meta-analysis. Compared with control intervention in migraine, PFO closure could significantly reduce headache frequency (OR = 1.5698, 95% CI: 1.0465–2.3548, p=0.0293) and monthly migraine attacks and monthly migraine days (OR = 0.2594, 95% CI: 0.0790–0.4398, p=0.0048). Subgroup analysis of patients who all completed PFO surgery showed resolution of migraine headache for migraines with aura (OR = 1.5856, 95% CI: 1.0665–2.3575, p=0.0227).

Conclusions

Treatment with PFO closure could reduce the frequency of headaches and monthly migraine days and is an efficient treatment for migraine attacks with aura.

Migraine and Stroke: In Search of Shared Pathways, Mechanisms, and Risk Factors

Migraines are one of the emerging causes of disabilities experienced worldwide, and strokes are the second leading cause of death globally. Migraines with aura have been reported to be associated with a higher risk of ischemic strokes, whereas hemorrhagic strokes are more closely associated with migraines without aura, possible mechanisms that link migraines to strokes. These can be categorized into vascular mechanisms such as vasospasm, endothelial and platelet dysfunction, and alteration in the vessel wall seen in migraineurs, further perpetrated by vascular risk factors such as hypertension and hyperlipidemias. Cerebral hypoperfusion that occurs in migraines can cause an electrical aberrance, leading to a phenomenon known as "spreading depression" which can contribute to strokes. In this review, we discuss bloodstream elevation in procoagulants such as antiphospholipid antibodies, homocysteine, von Willebrand factor, and prothrombin. Maintaining pregnant women who actively experience migraines with aura under close observation may be of some value in achieving better outcomes. Women who experience migraines after starting hormonal contraception are at a higher risk of experiencing strokes and stand to benefit from being switched to non-hormonal methods. In this article, we discuss the mechanisms linking migraines and strokes, briefly discuss the pathogenesis, and explore the risk factors contributing to the association therein. In addition, we examine the relationship between migraines and ischemic strokes, as well as hemorrhagic strokes, and review management considerations.

Migraine with Visual aura and the Risk of Stroke- a Narrative Review

OBJECTIVES

Patients with migraine with visual aura (MwvA) often present to eye care providers for evaluation. A thorough ophthalmological history and examination is needed to exclude ophthalmologic disorders. Additionally, it has been increasingly recognized that MwvA is associated with ischemic stroke (IS). The aim of this narrative review is to provide a comprehensive overview of the differential diagnosis of MwvA and its association with IS.

MATERIALS AND METHODS

We conducted a PubMed search using key words including "migraine aura", "visual aura without headache", "late onset migraine accompaniment", "migraine and stroke", "migraine and atrial fibrillation", and "migraine and patent foramen ovale (PFO)". We narratively summarized the main findings of the identified studies in sections including age of onset and frequency of migraine with aura, stroke subtypes, and the role of cardioembolism in the migraine-stroke association.

RESULTS AND CONCLUSION

For women younger than 50 years, MwvA is associated with an increased risk of IS, and the risk further increases in patients who also smoke and use oral contraceptives. Age of onset of MwvA 50 years or greater is associated with IS that occurs in late life. Studies reported that increased frequency of aura is associated with an increased risk of IS in women. MwvA is associated with an increased risk of cardioembolic stroke and a higher incidence of atrial fibrillation compared to migraine without aura. Most studies that assessed the migraine-stroke association were based on patients with MwvA. The risks of stroke associated with other types of migraine aura or aura without headache, as well as such association in men require further investigation. More data is needed to determine the absolute risk of stroke when evaluating MwvA in situations including smoking and low dose estrogen use, new or late onset (>50 years) MwvA, to facilitate the development of practice guidelines for stroke prevention in specific clinical scenarios.

Symptomatic migraine: A systematic review to establish a clinically important diagnostic entity

OBJECTIVE

To determine if a clinical presentation indistinguishable from migraine can occur due to an underlying condition or pathology, that is, "symptomatic migraine."

BACKGROUND

It is currently not clear whether migraine truly can be caused by an underlying condition or pathology. Characterization of the etiology and clinical features of possible symptomatic migraine is of significant clinical importance and further may help elucidate the pathophysiology of migraine.

METHODS

We devised operational diagnostic criteria for "symptomatic migraine" and "possible symptomatic migraine" requiring strong evidence for a causal relation between underlying cause and migraine symptoms adhering strictly to diagnostic criteria. PubMed was searched for case reports of symptomatic migraine from inception to March 2020. Only articles published in English or German were included. No restrictions were placed on study design. Relevant references in the articles were also included. Papers were systematically reviewed by two independent reviewers for detailed clinical features of migraine as well as the proposed underlying conditions and the effects of treatment of these conditions.

RESULTS

Our search retrieved 1726 items. After screening, 109 papers comprising 504 cases were reviewed in detail. Eleven patients with migraine with aura (MWA) fulfilled our working criteria for symptomatic migraine, and 39 patients fulfilled our criteria for possible symptomatic migraine. The most common etiologies of symptomatic migraine were arteriovenous malformations, carotid stenosis, dissection or aneurysm, brain infarctions, meningioma, and various intra-axial tumors.

CONCLUSIONS

Symptomatic MWA, indistinguishable from idiopathic MWA, may occur due to cortical lesions or microembolization. We found no clear evidence supporting the existence of symptomatic migraine without aura although we did identify possible cases. Our findings are limited by the available literature, and we suggest that prospective studies are needed.

Headache secondary to cerebrovascular disease

OBJECTIVES

To discuss headache secondary to cerebrovascular disease.

BACKGROUND

Headache is an important symptom in cerebrovascular diseases. In some conditions, headache is the leading symptom. Migraine is associated with an increased risk of stroke.

METHODS

The authors undertook a literature search for the terms "headache" and "cerebrovascular diseases".

RESULTS

We report studies on headache in subarachnoidal hemorrhage, intracerebral hemorrhage, ischemic stroke, TIA, basilar artery thrombosis, cervical artery dissection, cerebellar stroke, arteritis and cerebral sinus venous thrombosis. In addition, we discuss migraine and stroke and thunderclap headache.

CONCLUSIONS

Headache is a leading symptom in many cerebrovascular diseases. Headache in combination with focal neurological deficits requires immediate diagnosis and treatment.

The Efficacy of Percutaneous Patent Foramen Ovale Closure on Migraine: a Meta-Analysis of Randomized Controlled Trials and Observational Studies

Objectives

Whether patent foramen ovale (PFO) closure is effective on migraine is controversial. This article was aimed at assessing the efficacy of PFO closure on migraine based on randomized controlled trials (RCTs) and observational studies.

Methods

We searched PubMed, Embase, and Cochrane databases up to October 2020 evaluating PFO closure versus control in patients with migraine, then conducted a meta-analysis of all RCTs and observational studies, respectively. The main outcomes were (1) respond rate: complete cessation of migraine; (2) reduction in the frequency of migraine attacks per month; and (3) reduction in migraine days per month.

Results

Seven studies (3 RCTs and 4 observational studies), containing 887 migraine patients, were identified. (1) The respond rate of PFO closure on migraine was significantly higher than control group both in RCT subgroup and observational studies subgroup (OR 3.86, 95% CI 1.35-11.04, P = 0.01 in RCTs; OR 8.28, 95% CI 2.31-29.67, P = 0.001 in observational studies). (2) Reduction in frequency of migraine attacks was higher in PFO closure group compared with control group in the RCT subgroup analysis (mean difference (MD) = 0.57, 95% CI 0.23-0.90, P = 0.0009). (3) Reduction in migraine days was also higher in PFO closure group compared with control group in the RCT subgroup analysis (MD = 1.33, 95% CI 0.35-2.31, P = 0.008).

Conclusions

PFO closure might be suitable for migraine patients, especially for migraine with aura, by cessation of migraine headaches or reducing migraine attacks and migraine days.

Patent foramen ovale closure for secondary prevention of cryptogenic stroke

Introduction: A patent foramen ovale (PFO) is highly prevalent among the adult population. It allows shunting of blood through the inter-atrial septum and has been associated with cryptogenic stroke, transient ischemic attack, platypnea-orthodeoxia syndrome, decompression sickness (e.g. deep-water divers), and migraines.Areas Covered: In this manuscript, we will review the anatomy of PFO with particular emphasis on the factors associated with increased risk of paradoxical embolization, as well as the different modalities for the diagnosis of PFO. We will discuss medical, surgical, and transcatheter therapy for secondary prevention in patients with PFO and cryptogenic stroke, and summarize the data from observational studies, randomized controlled trials (RCTs), and meta-analysis of RCTs that have established the beneficial effect of transcatheter PFO closure in this patient population. Finally, we will provide a brief overview of the role of transcatheter PFO closure in patients with migraine.Expert Opinion: Transcatheter closure is the preferred treatment option in young (<60 years) patients with PFO and cryptogenic stroke. A multi-disciplinary approach with input from clinical cardiologist, neurologist, hematologist, cardiac surgeon, and interventional cardiologist provides the best therapeutic plan for each patient taking into account the available data, but also medical, social, and occupational considerations.

Pooled Analysis of PFO Occluder Device Trials in Patients With PFO and Migraine

BACKGROUND

Although observational studies have shown percutaneous patent foramen ovale (PFO) closure to be a safe means of reducing the frequency and duration of migraine, randomized clinical trials have not met their primary efficacy endpoints.

OBJECTIVES

The authors report the results of a pooled analysis of individual participant data from the 2 randomized trials using the Amplatzer PFO Occluder to assess the efficacy and safety of percutaneous device closure as a therapy for episodic migraine with or without aura.

METHODS

The authors analyzed individual patient-level data from 2 randomized migraine trials (the PRIMA [Percutaneous Closure of Patent Foramen Ovale in Migraine With Aura] and PREMIUM [Prospective Randomized Investigation to Evaluate Incidence of Headache Reduction in Subjects with Migraine and PFO Using the Amplatzer PFO Occluder Compared to Medical Management] studies). Efficacy endpoints were mean reduction in monthly migraine days, responder rate (defined as ≥50% reduction in monthly migraine attacks), mean reduction in monthly migraine attacks, and percentage of patients who experienced complete cessation of migraine. The safety endpoint was major procedure- and device-related adverse events.

RESULTS

Among 337 subjects, 176 were randomized by blocks to device closure and 161 to medical treatment only. At 12-month follow-up, the analysis met 3 of the 4 efficacy endpoints: mean reduction of monthly migraine days (-3.1 days vs. -1.9 days; p = 0.02), mean reduction of monthly migraine attacks (-2.0 vs. -1.4; p = 0.01), and number of subjects who experienced complete cessation of migraine (14 [9%] vs. 1 [0.7%]; p < 0.001). For the safety analysis, 9 procedure-related and 4 device-related adverse events occurred in 245 subjects who eventually received devices. All events were transient and resolved.

CONCLUSIONS

This pooled analysis of patient-level data demonstrates that PFO closure was safe and significantly reduced the mean number of monthly migraine days and monthly migraine attacks, and resulted in a greater number of subjects who experienced complete migraine cessation.

High Eosinophil Rates in Patients With Right-to-Left Shunts: An Expected Role, or an Unexpected Risk?

Background and objective Eosinophils are associated with thromboembolic events. Since eosinophils are eliminated in the pulmonary vasculature, right-to-left shunt (RLS) through patent foramen ovale may increase eosinophils in the peripheral blood. In this report, we evaluated the eosinophils of patients with regard to the presence of RLS and its quantity. Patients and methods In this retrospective observational study, we analyzed the complete blood cell count (CBC) of patients with RLS (n=47) and without RLS (n=31) diagnosed by contrast echocardiography (CE). RLS was identified as mild (5-10 bubbles) and moderate shunt (10-25 bubbles). Results Age and CBC were not significantly different between the groups, with the exception of eosinophils. Patients with RLS had higher eosinophils percentage compared to patients without RLS (3.1 ±1.5 vs. 1.7 ±0.7, p=0.001). Additionally, eosinophils percentage was significantly higher in the mild RLS group (2.4 ±0.9 vs. 1.7 ±0.7, p=0.016) and the moderate RLS group (4.3 ±1.6 vs. 1.7 ±0.7, p=0.001) compared to normal subjects. Also, it was significantly higher in the moderate RLS group compared to the mild group (4.3 ±1.6 vs. 2.4 ±0.9, p=0.001). Conclusions Eosinophils percentage was higher in patients with mild and moderate RLS compared to normal individuals. Moreover, the eosinophil rate was higher in patients with moderate RLS than in patients with mild RLS.

The Correlation Between Migraine and Patent Foramen Ovale

Background: Migraine is a widespread neurological disorder. The patent foramen ovale (PFO) is a remnant of the fetal circulation. Multiple studies suggest that migraine is more prevalent in subjects with PFO and vice versa. It is unclear if there is a causal relationship or simply a co-existence of these two conditions. Furthermore, the treatment of migraine with percutaneous closure PFO remains controversial.

Methods: We reviewed studies pertaining to the relationship between PFO and migraine as well as the effects of treatments on migraine attacks.

Results: We briefly summarized potential pathophysiological mechanisms of migraine, and elaborated on migraine type, frequency, and clinical symptoms of migraine with PFO and the clinical features of PFO with migraine. We also addressed the effects of PFO closure on migraine attacks.

Conclusion: The evidence supports a “dose-response” relationship between migraine and PFO although more work needs to be done in terms of patient selection as well as the inclusion of an antiplatelet control group for PFO closure interventions to uncover possible beneficial results in clinical trials.

Lasmiditan in patients with common migraine comorbidities: a post hoc efficacy and safety analysis of two phase 3 randomized clinical trials

OBJECTIVE

Determine whether common migraine comorbidities affect the efficacy and safety of lasmiditan, a 5-HT_1F receptor agonist approved in the United States for the acute treatment of migraine.

METHODS

In SPARTAN and SAMURAI (double-blind Phase 3 clinical trials), patients with migraine were randomized to oral lasmiditan 50 mg (SPARTAN only), 100mg, 200 mg, or placebo. Lasmiditan increased the proportion of pain-free and most bothersome symptom (MBS)-free patients at 2 h after dose compared with placebo. Most common treatment-emergent adverse events (TEAEs) were dizziness, paraesthesia, somnolence, fatigue, nausea, muscular weakness, and hypoesthesia. Based upon literature review of common migraine comorbidities, Anxiety, Allergy, Bronchial, Cardiac, Depression, Fatigue, Gastrointestinal, Hormonal, Musculoskeletal/Pain, Neurological, Obesity, Sleep, and Vascular Comorbidity Groups were created. Using pooled results, efficacy and TEAEs were assessed to compare patients with or without a given common migraine comorbidity. To compare treatment groups, p-values were calculated for treatment-by-subgroup interaction, based on logistic regression with treatment-by-comorbidity condition status (Yes/No) as the interaction term; study, treatment group, and comorbidity condition status (Yes/No) were covariates. Differential treatment effect based upon comorbidity status was also examined. Trial registration at clinicaltrials.gov: SAMURAI (NCT02439320) and SPARTAN (NCT02605174).

RESULTS

Across all the Comorbidity Groups, with the potential exception of fatigue, treatment-by-subgroup interaction analyses did not provide evidence of a lasmiditan-driven lasmiditan versus placebo differential treatment effect dependent on Yes versus No comorbidity subgroup for either efficacy or TEAE assessments.

CONCLUSIONS

The efficacy and safety of lasmiditan for treatment of individual migraine attacks appear to be independent of comorbid conditions.

Cardiac sources of cerebral embolism in people with migraine

BACKGROUND AND PURPOSE

Whether the reported association between migraine with aura (MA) and cardioembolic stroke may be explained by a higher rate of atrial fibrillation (AF) or by other potential cardiac sources of cerebral embolism remains to be determined.

METHODS

In the setting of a single centre cohort study of consecutive patients with acute brain ischaemia stratified by migraine status, the association between AF as well as patent foramen ovale (PFO) and migraine was explored.

RESULTS

In all, 1738 patients (1017 [58.5%] men, mean age 67.9 ± 14.9 years) qualified for the analysis. Aging was inversely associated with migraine, whilst women had a >3-fold increased disease risk (odds ratio [OR] 3.82, 95% confidence interval [CI] 2.58-5.66). No association between AF and history of migraine or its pathogenic subtypes was detected. Conversely, migraine was associated with PFO, both in the entire cohort (OR 1.84, 95% CI 1.07-3.16) and in patients aged ≤55 years (OR 2.21, 95% CI 1.16-4.22). This association was significant for MA (OR 2.92, 95% CI 1.32-6.45 in the entire cohort; OR 2.92, 95% CI 1.15-7.41 in patients aged ≤55 years) and in women (OR 8.23, 95% CI 2.06-32.77), but not for migraine without aura.

CONCLUSIONS

In patients with brain ischaemia migraine is not associated with AF. Conversely, there is a probable relation between migraine, especially MA, and PFO in patients who are younger and have a more favourable vascular risk factor profile, and in women.

A Nomogram for the Prediction of Cessation of Migraine Among Patients With Patent Foramen Ovale After Percutaneous Closure

Objective: This study aimed to develop and validate a nomogram to predict cessation of patent foramen ovale (PFO) patients with migraine headache after percutaneous closure.

Methods: A total of 247 eligible patients with PFO and migraine after percutaneous closure between May, 2016 and May, 2018 were divided into a development cohort (n = 149) and a validation cohort (n = 98). The primary end point was cessation of migraine at follow-up of 1 year after the procedure measured by the Migraine Disability Assessment Score (MIDAS). In the development cohort, the LASSO regression was used data dimension reduction. A multivariable logistic regression analysis was used to develop the predicting nomogram. The performance of the nomogram was assessed by concordance index (C-index), calibration and clinical usefulness. The results were validated in the validation cohort.

Results: Migraine with aura, history of antiplatelet, and the right-to-left shunt (RLS) at rest were identified as significant predictors based on the analysis of multivariate logistic regression. The nomogram incorporating these variables showed good calibration and discrimination in the development cohort with C-index of 0.906 (95% CI: 0.847–0.965), which was confirmed using the validation cohort with C-index of 0.827 (95% CI: 0.751–0.903). The nomogram showed good agreement between prediction by nomogram and actual observation. Furthermore, the decision curve indicated that the novel nomogram was clinically useful.

Conclusion: The novel nomogram showed favorable predictive accuracy for cessation of migraine among patients with PFO after percutaneous closure and might provide constructive guidance in clinical decision making.

Efficacy of patent foramen ovale closure for treating migraine: a prospective follow-up study

This study aims to evaluate the potential of percutaneous patent foramen ovale (PFO) closure to improve the headache in patients with migraine and PFO, and discuss the difference between the randomized controlled trials (RCTs) and the single-center studies. Patients of migraine with a large shunt of PFO, who experienced ≥2 headache attacks per month and failed ≥2 categories of standardized medication, underwent PFO closure in First Affiliated Hospital of Xi'an Jiao Tong University. The clinical outcomes, including frequency and duration of headache attacks, Headache Impact Test (HIT-6) score, and Visual Analogue Scale (VAS) score, were evaluated at 3, 6, and 12 months of follow-up after the PFO closure. The different efficacies of the clinical outcomes between patients with and without aura as well as different grades of PFO were also evaluated, respectively. 134 patients with migraine (39 male and 95 female) with PFO were enrolled, whose average age was 39.21±11.37 years. After PFO closure, there was a significant reduction in frequency and duration of headache attacks, HIT-6 score, and VAS score at 3, 6, and 12 months’ follow-up (p<0.001). Migraine was completely relieved in 54 (40.30%) patients during 12 months’ follow-up. The frequency of migraine was reduced by >50% in 44 (32.84%) patients at 3 months’ follow-up and increased to 48 (35.82%) at 12 months’ follow-up. 31.03% patients remained residual shunt after 6 months of closure with varying improvements of headache. This study confirmed that PFO closure can effectively reduce frequency and duration of migraine and improve quality of life, but the definitive indications and long-term effect still need further research.

Migraine and risk of stroke

Migraine and stroke are two common and heterogeneous neurovascular disorders responsible for a significant burden for those affected and a great economic cost for the society. There is growing evidence that migraine increases the overall risk of cerebrovascular diseases. In this review, based on available literature through a PubMed search, we found that ischaemic stroke in people with migraine is strongly associated with migraine with aura, young age, female sex, use of oral contraceptives and smoking habits. The risk of transient ischaemic attack also seems to be increased in people with migraine, although this issue has not been extensively investigated. Although migraine appears to be associated with haemorrhagic stroke, the migraine aura status has a small influence on this relationship. Neuroimaging studies have revealed a higher prevalence of asymptomatic structural brain lesions in people with migraine. They are also more likely to have unfavourable vascular risk factors; however, the increased risk of stroke seems to be more apparent among people with migraine without traditional risk factors. The mechanism behind the migraine-stroke association is unknown. In light of the higher risk of stroke in people with migraine with aura, it is important to identify and modify any vascular risk factor. There is currently no direct evidence to support that a migraine prophylactic treatment can reduce future stroke in people with migraine.

Epidemiology of Patent Foramen Ovale in General Population and in Stroke Patients: A Narrative Review

Introduction: Percutaneous closure of patent foramen ovale (PFO) in selected patients with cryptogenic cerebrovascular ischemic events (CEs) decreases the risk of recurrent stroke; however, optimal patient selection criteria are still under investigation. Candidates for PFO closure are usually selected from the pool of CE patients with a high risk of Paradoxical Embolism (RoPE) score. The RoPE score calculates the probability that PFO is causally related to stroke, based on PFO prevalence in patients with CE compared with that in healthy subjects. The latter has been set at 25% based on the average of autopsy and transesophageal echocardiography (TEE) studies.

Methods: We conducted a comprehensive review of studies investigating PFO prevalence in general population and in patients with CE and non-CE using autopsy, TEE, transcranial Doppler (TCD) or transthoracic echocardiography (TTE). Studies were excluded if they (1) reported data from referred subjects with underlying cerebrovascular disease or (2) did not specify etiologically the events.

Results: In healthy/control subjects, PFO prevalence was 24.2% (1,872/7,747) in autopsy studies, 23.7% (325/1,369) in TEE, 31.3% (111/355) in TCD, and 14.7% (186/1,267) in TTE studies. All diagnostic modalities included PFO prevalence was higher in CE compared with healthy/control population [odds ratio (OR) = 3.1, 95% confidence interval (CI) = 2.5–3.8] and compared with non-CE (OR = 2.3, 95% CI = 2.0–2.6). In patients with CE, PFO prevalence in the young compared to the old was higher when the diagnostic modality was TEE (48.9 vs. 27.3%, p < 0.0001, OR = 2.6 with 95% CI = 2.0–3.3) or TCD (58.1 vs. 41%, OR = 1.9, 95% CI = 1.6–2.5), but not TTE (53.3 vs. 37.5%, p = 0.16). Regarding non-CE, PFO prevalence in the young compared to the old was higher when the diagnostic modality was TEE (20 vs. 12.9%, OR = 1.7, 95% CI = 1.0–2.8) but not TTE (10.4 vs. 7.8%, p = 0.75) or TCD (22.8 vs. 20.1%, p = 0.56).

Conclusions: Given the limitations of autopsy and TEE studies, there is good reason not to take a fixed 25% PFO prevalence for granted. The estimation of degree of causality may be underestimated or overestimated in populations with PFO prevalence significantly lower or higher than the established. Given the high sensitivity, non-invasive nature, low cost, and repeatability of TCD, future large-scale TCD-based studies should investigate potential heterogeneity in PFO prevalence in different healthy racial/ethnic populations.

Patent foramen ovale

Patent foramen ovale (PFO) is the most common anatomical cause of an interatrial shunt. It is usually asymptomatic but may cause paradoxical embolism, manifesting as stroke, myocardial infarction or visceral/peripheral ischaemia. PFO is a risk factor for stroke and may be associated with migraine with aura. New evidence suggests PFO closure reduces the risk of recurrent ischaemic stroke in a highly selected population of stroke survivors: those aged 60 years or younger with a cryptogenic stroke syndrome, a large right-to-left shunt, an atrial septal aneurysm and no evidence of atrial fibrillation. They benefit from percutaneous PFO closure in addition to antiplatelet therapy, rather than antiplatelet therapy alone. Current evidence does not support PFO closure in the treatment of migraine.

The Connection Between Patent Foramen Ovale and Migraine

"Observational studies have identified a relationship between patent foramen ovale (PFO) and migraine headache. In people who have migraine with aura, 40% to 60% have a PFO, compared with 20% to 30% in the general adult population. It is hypothesized that migraine, especially migraine with aura, may be triggered by hypoxemia or vasoactive chemicals (eg, serotonin), which are ordinarily metabolized during passage through the lungs. Although PFO closure is currently not a FDA-approved therapy for migraines, randomized trials suggest that this intervention may benefit a subgroup of migraineurs."

Transcatheter Patent Foramen Ovale Closure Is Effective in Alleviating Migraine in a 5-Year Follow-Up

Background: The association between patent foramen ovale (PFO) and migraine has been reported. However, whether transcatheter PFO closure is effective in alleviating migraine remains controversial. The objective of this study was to investigate the efficacy of PFO closure in alleviating migraine in a 5-year follow-up.

Methods: Migraineurs with PFO from 2013 to 2015 were included and divided into PFO closure group and non-PFO closure group according to their therapy. Contrast-enhanced transcranial Doppler (c-TCD) was performed to evaluate the degree of the right-to-left shunt (RLS), and headache impact test (HIT-6) questionnaire was administered to assess the disability of migraine at 1- and 5-year follow-up.

Results: Of 192 patients, 91 patients underwent PFO closure, and 101 patients refused. The HIT-6 scores of patients in the PFO closure group were significantly lower than those of the non-PFO closure group at both 1- and 5-year follow-up. These results were more pronounced in patients younger than 45 years. Furthermore, in patients with large RLS, the HIT-6 scores of patients in the PFO closure group were significantly lower at both 1- and 5-year follow-up compared with those of the non-PFO closure group. However, in patients with moderate RLS, this difference was significant only at 5-year follow-up.

Conclusions: PFO closure is effective in alleviating migraine in the long term. This effect is more obvious when patients are younger than 45 years and RLS is large.

Impact of right-to-left shunt and transcatheter closure on the clinical features of migraine

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.

Ticagrelor for Refractory Migraine/Patent Foramen Ovale (TRACTOR): An open-label pilot study

OBJECTIVE

After finding that the thienopyridines clopidogrel and prasugrel reduced migraine headache (MHA) symptoms in some patients with patent foramen ovale (PFO), this small pilot study was undertaken to determine whether ticagrelor, a nonthienopyridine P2Y12 inhibitor, would have similar MHA effects and might be better suited for a future randomized trial.

METHODS

MHA patients were screened for PFO. Participants with documented right to left shunt (RLS) and ≥6 monthly MHA days received ticagrelor therapy for 28 days. Those with ≥50% reduction in monthly MHA days were deemed responders and completed 2 additional treatment months.

RESULTS

The 40 participants had a mean age of 36.2 years and mean MHA frequency of 17.4 d/mo. A total of 39/40 were female. A total of 14/40 met criteria for episodic MHA, 26/40 for chronic MHA, 14/40 had migraine with aura, and 22/40 had a moderate-large RLS (Spencer grade ≥4). Seventeen of 40 participants (43%) were responders. MHA reduction continued through 3 treatment months in all responders. MHA responder rates were not statistically different in participants with episodic or chronic MHA, with or without aura, or with small/larger RLS shunt magnitude. Thirteen (32%) patients had medication side effects, without serious adverse events.

CONCLUSION

P2Y12 inhibition with ticagrelor reduced MHA symptoms similarly to our previous thienopyridine experience, but participants seemed to have a less robust MHA benefit and more frequent side effects than with the thienopyridines, making it an inferior choice for a randomized trial.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that ticagrelor reduced MHA symptoms in patients with PFO.

Clinical features of visual migraine aura: a systematic review

Background

Migraine aura (MA) is a common and disabling neurological condition, characterized by transient visual, and less frequently sensory and dysphasic aura disturbances.

MA is associated with an increased risk of cardiovascular disorders and is often clinically difficult to distinguish from other serious neurological disorders such as transient ischemic attacks and epilepsy. Optimal clinical classification of MA symptoms is important for more accurate diagnosis and improved understanding of the pathophysiology of MA through clinical studies.

Main body

A systematic review of previous prospective and retrospective systematic recordings of visual aura symptoms (VASs) was performed to provide an overview of the different types of visual phenomena occurring during MA and their respective frequencies in patients. We found 11 retrospective studies and three prospective studies systematically describing VASs. The number of different types of VASs reported by patients in the studies ranged from two to 23. The most common were flashes of bright light, “foggy” vision, zigzag lines, scotoma, small bright dots and ‘like looking through heat waves or water’.

Conclusions

We created a comprehensive list of VAS types reported by migraine patients based on all currently available data from clinical studies, which can be used for testing and validation in future studies. We propose that, based on this work, an official list of VAS types should be developed, preferably within the context of the International Classification of Headache Disorders of the International Headache Society.

Meta-analysis of randomized trials on percutaneous patent foramen ovale closure for prevention of migraine

BACKGROUND

The role of percutaneous patent foramen ovale (PFO) closure for prevention of migraine is controversial.

METHODS

We performed a computerised search of MEDLINE, EMBASE and COCHRANE databases through December 2017 for randomised trials evaluating PFO closure versus control in patients with migraine headaches (with or without aura). The main study outcome was the reduction in monthly migraine attacks after PFO closure compared with the control group.

RESULTS

The final analysis included three randomised trials with a total of 484 patients. Reduction in monthly migraine attacks was higher in PFO closure compared with the control group (standardised mean difference-SMD = 0.25; 95% CI: 0.06-0.43; p = .01). There was higher reduction of monthly migraine days in PFO closure group compared with control group (SMD = 0.30; 95% CI: 0.08-0.53; p = .01). There was no statistically significant difference in complete resolution of migraine attacks (OR: 3.67; 95% CI: 0.66-20.41; p = .14) and in responders' rate (OR: 1.92; 95% CI: 0.76-4.85; p = .17) between PFO closure and control groups. In patients whose majority of migraine attacks are with aura, there was an observed reduction in migraine attacks in PFO closure compared with control groups (SMD = 0.86; 95% CI: 0.07-1.65; p = .03).

CONCLUSION

PFO closure might be beneficial in migraine patients by reducing migraine attacks and migraine days, especially in patients whose majority of migraine attacks are with aura. However, those benefits were not associated with an improvement in responders' rate or complete resolution of migraine; raising concerns on the magnitude of clinical benefit of PFO closure in migraine prevention.

Migraine Age of Onset and Association With Ischemic Stroke in Late Life: 20 Years Follow-Up in ARIC

BACKGROUND AND PURPOSE

To evaluate the association between cumulative exposure to migraine and incidence of ischemic stroke in the Atherosclerosis Risk in Communities (ARIC) study.

METHODS

In this ongoing, prospective longitudinal community-based cohort, participants were interviewed to ascertain migraine history at the third visit (1993-1995), followed for ischemic stroke incidence over 20 years. We performed a post hoc analysis to evaluate the association between the age of migraine onset and ischemic stroke.

RESULTS

We identified 447 migraineurs with aura (MA) and 1128 migraineurs without aura (MO) among 11,592 black and white participants. There was an association between the age of MA onset ≥50 years old (average duration = 4.75 years) and ischemic stroke when compared to no headache group (multivariable adjusted HR = 2.17, 95% CI [1.39-3.39], P < .001). MA onset <50 years old (average duration = 28.17 years) was not associated with stroke (multivariable adjusted HR = 1.31, 95% CI [0.86-2.02], P = .212). These results were consistent with our logistic regression model. MO was not associated with increased stroke regardless of the age of onset. The absolute risk for stroke in migraine with aura is 37/447 (8.27%) and migraine without aura is 48/1128 (4.25%).

CONCLUSION

As compared to the no headache participants, increased stroke risk in late life was observed in participants with late onset of MA. In this cohort, longer cumulative exposure to migraine with visual aura, as would be expected with early onset of migraine, was not associated with increased risk of ischemic stroke in late life. This study underscores the importance of the age of onset of MA in assessing stroke risk in older migraineurs.

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 and cerebrovascular disease: still a dangerous connection?

Migraine is a common type of headache in young adults, with an estimated prevalence of 4% before puberty and as high as 25% in women by their mid to late 30s. About one third of migraineurs experience transient neurological symptoms known as auras, which characterize a variant known as migraine with aura. Many evidences have shown an increased risk of vascular events in patients affected by migraine, particularly among women and among migraine patients with aura. Potential underlying mechanisms include endothelial dysfunction, hypercoagulability, platelet aggregation, vasospasm, cardiovascular risk factors, paradoxical embolism, spreading depolarization, shared genetic risk, use of non-steroidal anti-inflammatory drugs, and immobilization. The risk of vascular events in migraine patients is also linked by concomitant oral contraception; moreover, the common finding of increased incidence of right to left cardiac shunt in migraine patients might have a pathogenetic role. Finally, many MRI studies in migraine patients, particularly in migraine with aura, have shown subcortical lesions particularly in the cerebellum as a common finding. In this review, we analyzed the more recent findings regarding the topic of migraine as a risk factor in stroke.

Frequency of Patent Foramen Ovale and Migraine in Patients With Cryptogenic Stroke

BACKGROUND AND PURPOSE

Individuals with migraine are at higher risk for stroke, but the mechanism has not been established. On the basis of the association between migraine and intracardiac right-to-left shunt, it has been proposed that stroke in migraineurs could be caused by a paradoxical embolus passing through a patent foramen ovale (PFO) or pulmonary arteriovenous malformation. The aim of this study was to determine the prevalence of PFO with right-to-left shunt in patients who presented with cryptogenic stroke and had a history of migraine.

METHODS

Patients between 18 and 60 years old who presented with an ischemic stroke were characterized based on ASCOD phenotyping (atherosclerosis; small-vessel disease; cardiac pathology; other causes; dissection). A migraine diagnosis was identified by reviewing physician notes, and frequent aura was defined if present in at least 50% of attacks. A PFO with right-to-left shunt diagnosis was identified by the presence of a positive bubble contrast study with either transcranial Doppler, transthoracic, or transesophageal echocardiography.

RESULTS

Of the 712 patients who presented with ischemic stroke, 127 (18%) were diagnosed as cryptogenic; 68 patients had adequate testing for PFO and a documented migraine history. The prevalence of PFO in patients with cryptogenic stroke without migraine was elevated (59%) compared with the general population (18%). Patients with both cryptogenic stroke and migraine had a higher prevalence of PFO (79%). In patients with cryptogenic stroke who had migraine with frequent aura, the prevalence of PFO was 93%. Only 5 patients (4%) had a history compatible with migrainous infarction.

CONCLUSIONS

In patients with cryptogenic stroke who have migraine, there is a high prevalence (79%) of PFO with right-to-left shunt. The timing of the stroke in migraineurs is usually not related to a migraine attack. These observations are consistent with the hypothesis that the mechanism of stroke in migraineurs is most likely because of a paradoxical embolus. Future cryptogenic stroke classification schemes should consider including PFO as a separate etiologic category.

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.