Migraine and patent foramen ovale: connecting flight or one-way ticket?

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)

Long-term follow-up after percutaneous closure of patent foramen ovale with Amplatzer PFO Occluder: a single center experience

Introduction

Patent foramen ovale (PFO) is associated with the occurrence of cryptogenic strokes, transient neurological ischemic attacks (TIA) and migraine. Therefore despite the recent ambiguous results of prospective controlled trials, percutaneous closure of PFO is still performed in many centers.

Aim

To evaluate the safety and effectiveness of percutaneous PFO closure in the prevention of recurrence of neurologic events and migraine symptoms in long-term observation.

Material and methods

In 70 patients (31 male, age: 38 ±18 years) percutaneous PFO closure was successfully performed with the Amplatzer PFO Occluder. An interview in conjunction with neurological follow-up was performed in all patients to reveal recurrence of embolism such as TIA or stroke and the presence of migraine symptoms before and after the procedure.

Results

The mean follow-up period was 857 ±363 days (median: 571 days). No serious complications of the procedure and no death were observed. Neurological events recurred in 5 (7.1%) patients – stroke in 1 patient, TIA in 3 patients, ocular embolism in 1 patient. All of these patients were over 40 years old or had other cardiovascular risk factors. Migraine was observed in 21 (30%) patients before the procedure and in 11 (15.7%) after the procedure (p = 0.04).

Conclusions

The complication rate and recurrence of neurological events in young patients after PFO closure are low. However, careful qualification and postprocedural monitoring of the patients are necessary. Patent foramen ovale closure seems to result in attenuation of migraine symptoms.

Recent progress in migraine pathophysiology: role of cortical spreading depression and magnetic resonance imaging

Migraine is characterised by debilitating pain, which affects the quality of life in affected patients in both the western and the eastern worlds. The purpose of this article is to give a detailed outline of the pathophysiology of migraine pain, which is one of the most confounding pathologies among pain disorders in clinical conditions. We critically evaluate the scientific basis of various theories concerning migraine pathophysiology, and draw insights from brain imaging approaches that have unraveled the prevalence of cortical spreading depression (CSD) in migraine. The findings supporting the role of CSD as a physiological substrate in clinical pain are discussed. We also give an exhaustive overview of brain imaging approaches that have been employed to solve the genesis of migraine pain, and its possible links to the brainstem, the neocortex, genetic endophenotypes, and pathogenetic factors (such as dopaminergic hypersensitivity). Furthermore, a roadmap is proposed to provide a better understanding of pain pathophysiology in migraine, to enable the development of strategies using leads from brain imaging studies for the identification of early biomarkers, efficient prognosis, and treatment planning, which eventually may help in alleviating some of the devastating impact of pain morbidity in patients afflicted with migraine.

Frequency of the C677T variant of the methylenetetrahydrofolate reductase (MTHFR) gene in patients with migraine with or without aura - a preliminary report

BACKGROUND AND PURPOSE

The aim of our study was to evaluate the frequency of the C677T variant in the methylenetetrahydrofolate reductase (MTHFR) gene in patients with migraine with or without aura and to find an association between this variant and vascular lesions in magnetic resonance imaging of the head, presence of patent foramen ovale (PFO) and increased level of homocysteine.

MATERIAL AND METHODS

Ninety-one patients with migraine, aged 19-57, were investigated in this study. The MTHFR C677T variant was genotyped in this group and levels of homocysteine, folic acid and vitamin B12 were measured. Transcranial Doppler sonography with test for PFO detection by injection of air contrast during the Valsalva manoeuvre was performed in each patient.

RESULTS

Frequency of the C677T variant in the MTHFR gene was similar in patients and controls. Hyperhomocysteinaemia was significantly more frequent in migraine patients with the C677T variant. The prevalence of PFO was significantly higher in migraine patients with aura and the homozygous variant of the MTHFR gene.

CONCLUSIONS

Frequency of the C677T variant in the MTHFR gene was similar in patients and controls. Significantly more frequent prevalence of PFO in migraine patients with aura (with homozygous recessive genotype of MTHFR probably suggests their common genetic basis. Hyperhomocysteinaemia was significantly more frequent in migraine patients with the C677T variant, which could be an additional risk factor of this disease.

Paradoxical air microembolism induces cerebral bioelectrical abnormalities and occasionally headache in patent foramen ovale patients with migraine

BACKGROUND

Although controversial, paradoxical embolism via patent foramen ovale (PFO) may account for some of the migraine attacks in a subset of migraine with aura (MA) patients. Induction of MA attacks with air bubble injection during transcranial Doppler ultrasound in MA patients with PFO supports this view. It is likely that cerebral embolism in patients with right-to-left shunt induces bioelectrical abnormalities to initiate MA under some conditions.

METHODS AND RESULTS

We investigated changes in cerebral bioelectrical activity after intravenous microbubble injection in 10 MA patients with large PFO and right-to-left cardiac shunt. Eight PFO patients without migraine but with large right-to-left shunt and 12 MA patients without PFO served as controls. Four MA patients with PFO were reexamined with sham injections of saline without microbubbles. Bioelectrical activity was evaluated using spectral electroencephalography and, passage of microbubbles through cerebral arteries was monitored with transcranial Doppler ultrasound. Microbubble embolism caused significant electroencephalographic power increase in MA+PFO patients but not in control groups including the sham-injected MA+PFO patients. Headache developed in 2 MA with PFO patients after microbubble injection.

CONCLUSIONS

These findings demonstrate that air microembolism through large PFOs may cause cerebral bioelectrical disturbances and, occasionally, headache in MA patients, which may reflect an increased reactivity of their brain to transient subclinical hypoxia-ischemia, and suggest that paradoxical embolism is not a common cause of migraine but may induce headache in the presence of a large PFO and facilitating conditions.

Patent foramen ovale: a comprehensive review for pulmonologists

PURPOSE OF REVIEW

A comprehensive review of the main concepts about patent foramen ovale (PFO) management is offered.

RECENT FINDINGS

PFO is a common, usually benign, anatomical variant that in the presence of a discrete right-to-left shunt and other predisposing factors (Eustachian valve/Chiari network, atrial septal aneurysm, and coagulation cascade abnormalities) may play an important role in the patho-physiology of paradoxical embolism at different levels (cryptogenic stroke, peripheral embolism, coronary embolism, etc.). Therapy is a controversial issue, since data on these patients are variable and accepted guidelines are missing. Recurrent strokes are the most diffuse and accepted indication for transcatheter closure of PFO, but severe refractory migraine with aura, unexplained oxygen desaturation, orthodeoxia-platypnea, and other conditions have been suggested to benefit from PFO closure. Different devices and techniques have been proposed for this procedure, mainly depending on operator experience and preferences, which have contributed to this intervention becoming a well tolerated and effective procedure with very low morbidity and virtually absent mortality.

SUMMARY

PFO management is still a debated field: indications, pathophysiology and ideal closure techniques remain to be fully clarified and investigated before considering PFO closure a routine procedure.

Left atrial dysfunction in patients with patent foramen ovale and atrial septal aneurysm scheduled for transcatheter closure may play a role in aura genesis

BACKGROUND

It has been suggested that a left atrial (LA) dysfunction induced by large shunt and large atrial septal aneurysm (ASA) may act as a concurrent mechanism of arterial embolism in patients with patent foramen ovale (PFO) and prior stroke. We aimed to evaluate the potential contribution of this mechanism as trigger of migraine in patients with PFO.

METHODS

From January 2007 to September 2009, we prospectively enrolled subjects with migraine who underwent percutaneous PFO closure. Echocardiographic parameter of LA dysfunction was evaluated: pre- and postoperative values were compared to values of different sex and heart rate matched populations: 30 healthy patients, 21 migraine patients without PFO (MwoPFO), and a group of 25 PFO patients without migraine (PFOwoM). The Migraine Disability Assessment Score (MIDAS) was used to assess the incidence and severity of migraine.

RESULTS

Forty-five patients (38 females, mean age 38 +/- 6.7 years, mean MIDAS 35.8 +/- 4.7, and 28 patients with migraine with aura) fulfilled the inclusion criteria. After successful percutaneous closure (mean follow-up of 18.2 +/- 4.8 months), PFO closure remained complete in 95%; 35 of 45 patients reported resolution or amelioration of migraine (mean MIDAS score 12.3 +/- 8.8, P < 0.03). All patients with aura reported aura resolution. Preclosure values demonstrated significantly greater LA dysfunction, when compared with healthy and MwoPFO groups. Among patients in the study group, only patients with migraine with aura showed LA dysfunction comparable to PFOwoM patients.

CONCLUSION

This study suggests that LA dysfunction probably does not contribute to migraine itself but may play a role in the genesis of aura symptoms.

Migraine aura pathophysiology: the role of blood vessels and microembolisation

Migraine attacks with auras are sometimes associated with underlying hereditary or acquired cerebrovascular disorders. A unifying pathophysiological explanation linking migraine to these conditions has been difficult to identify. On the basis of genetic and epidemiological evidence, we suggest that changes in blood vessels, hypoperfusion disorders, and microembolisation can cause neurovascular dysfunction and evoke cortical spreading depression, an event that is widely thought to underlie aura symptoms. In fact, recent experimental data have indicated that focal, mild, and transient ischaemia can trigger cortical spreading depression without an enduring tissue signature. Although migraine with aura has many causes (eg, neuronal network excitability), it seems that migraine and stroke might both be triggered by hypoperfusion and could therefore exist on a continuum of vascular complications in a subset of patients who have these hereditary or acquired comorbid vascular conditions.

Microemboli may link spreading depression, migraine aura, and patent foramen ovale

OBJECTIVE

Patent foramen ovale and pulmonary arteriovenous shunts are associated with serious complications such as cerebral emboli, stroke, and migraine with aura. The pathophysiological mechanisms that link these conditions are unknown. We aimed to establish a mechanism linking microembolization to migraine aura in an experimental animal model.

METHODS

We introduced particulate or air microemboli into the carotid circulation in mice to determine whether transient microvascular occlusion, insufficient to cause infarcts, triggered cortical spreading depression (CSD), a propagating slow depolarization that underlies migraine aura.

RESULTS

Air microemboli reliably triggered CSD without causing infarction. Polystyrene microspheres (10 microm) or cholesterol crystals (<70 microm) triggered CSD in 16 of 28 mice, with 60% of the mice (40% of those with CSD) showing no infarcts or inflammation on detailed histological analysis of serial brain sections. No evidence of injury was detected on magnetic resonance imaging examination (9.4T; T2 weighted) in 14 of 15 selected animals. The occurrence of CSD appeared to be related to the magnitude and duration of flow reduction, with a triggering mechanism that depended on decreased brain perfusion but not sustained tissue damage.

INTERPRETATION

In a mouse model, microemboli triggered CSD, often without causing microinfarction. Paradoxical embolization then may link cardiac and extracardiac right-to-left shunts to migraine aura. If translatable to humans, a subset of migraine auras may belong to a spectrum of hypoperfusion disorders along with transient ischemic attacks and silent infarcts.

Migraine and the Risk of Coronary Heart Disease and Ischemic Stroke in Women

Migraine is a common chronic disorder, especially amongst women – approximately 18% of US women will have had a migraine attack within the past year. Cardiovascular disease is the biggest killer in the same population. This review summarizes the best available epidemiological evidence for an independent association between migraine and cardiovascular disease amongst women. The most reliable evidence comes from the Women's Health Study, which found that migraine with aura raised the risk of ischemic stroke by 91% (95% CI: 17–210%) and myocardial infaction by 108% (95% CI: 30–231%). Migraine without aura raised both risks by approximately 25%. The other prospective studies that were identified gave broadly supportive results, and suggested that the risks from migraine were attenuated with age. It would be prudent for women who suffer migraine with aura to seek medical advice and consider lifestyle changes in order to improve their cardiovascular risk profile.