Patients find long-term migraine relief after PFO closure

A study published in JACC: Cardiovascular Interventions this month found that patients who suffer from migraines may find long-term relief after transcatheter patent foramen ovale (PFO) closure.

Past research suggests patients with PFO are at an increased risk for migraines—in their paper, first author Eyal Ben-Assa, MD, and colleagues wrote that such individuals are up to three times more likely than their peers to experience the splitting headaches. Migraine sufferers with PFO have more often presented with atrial septal aneurysm, large right-to-left shunt and aura, a migraine “warning sign” that consists of visual symptoms like flashing lights and blind spots.

“Multiple studies have reported improvement in migraine symptoms after transcatheter PFO closure, yet three randomized trials that followed patients for 6 to 12 months failed to reach their primary endpoints,” Ben-Assa, of Massachusetts General Hospital and Tel Aviv Sourasky Medical Center in Tel Aviv, Israel, et al. wrote in JACC. “Interestingly, in all of these randomized studies, there were subgroups demonstrating significant improvement in their migraine symptoms after device closure.”

Ben-Assa and his team retrospectively analyzed data from 474 patients for their study, all of whom underwent transcatheter PFO closure at Massachusetts General. Migraine burden was determined via questionnaires at baseline and follow-up, and migraine severity was defined as a composite of migraine frequency, average duration and migraine burden.

The authors tracked their study population for an average of 3.2 years, ultimately including 110 migraineurs who underwent PFO closure in their analysis. Of that group, 77% presented with aura and 23% presented without. Ninety-one percent had a cryptogenic stroke.

Ben-Assa et al. noted significant improvement—defined as complete abolishment of symptoms or a 50% or greater reduction in migraine burden—in patients’ symptoms over long-term follow-up, both in individuals with and without aura. Migraine burden was reduced by 50% or more in 87% of patients, and symptoms were eradicated completely in 48%.

The team said the presence of aura was a major predictor for migraine relief, resulting in a more than fourfold increased likelihood of migraine abolishment. Absence of right-to-left shunt was also linked to a 4.6-fold increased likelihood of improvement in migraine burden; at six months, residual right-to-left shunt was present in 26% of patients.

Stéphane Noble, MD, of University Hospital of Geneva in Geneva, Switzerland, lauded Ben-Assa and his colleagues in a related editorial, noting that previous studies connecting PFO and migraines hadn’t specifically addressed the effect of residual shunt on migraine improvement. Noble said the team’s research suggests “complete closure” of the PFO might be the best route for people who suffer from migraines, while “effective closure” may be sufficient for stroke prevention alone.

“This study further contributes to show the correlation between PFO and migraine,” Noble wrote. “It highlights the presence of aura as a predictor of migraine abolishment and raises the point that residual shunt post-PFO closure is potentially an important factor to include in future randomized trials in the migraine population.

“It is time to perform such a study now that the question of secondary stroke prevention is clearer.”