Splitting headaches with nausea and visual disturbances seriously interfere with your quality of life. Year after year migraine sufferers stoically endure the passing storm of these debilitating symptoms, rarely finding alleviation in the offerings of the pharmaceutical industry.
Fortunately, it seems there may be an alternative route. For several years now, researchers have linked migraines to a small hole in the heart: the PFO (perforated foramen ovale). This is a small hole in the atrial septum, the dividing wall between the right and the left atrium, which should close at birth with our first deep breath. However, in about 25% of cases this does not occur and although it may not create any other symptoms, it may be responsible for your migraines.
A recent review in the journal ‘Frontiers in Neurology’ was dedicated to this problem. It turns out that PFO is the most common congenital (from birth) cardiac anomaly. In 1998 several studies noticed a clear correlation between the incidence of PFO and migraines: 14.6% to 66.5% of patients with a PFO suffer from migraines, whilst the incidence in the general populations ranges from 9% to 27.3%. When looking at patients with migraines associated with aura, the visual or sensory disturbances often associated with the headache attacks, research shows 46.3%-88% patients had a PFO, depending on the study. These results suggest that at least half of the people with aura-associated migraines will have a PFO.
Why is there a correlation between these two health issues?
One potential explanation involves the effect of vasoactive substances (e.g. serotonin), which bypasses the pulmonary circulation and goes directly to the brain where it potentially causes migraine. Another explanation focuses on small emboli in the venous systemic circulation passing through the PFO and into the arterial system, which may lead to tiny brain infractions triggering low perfusion and causing a migraine attack.
So what happens if we simply close the PFO?
There is a minimally invasive procedure called a percutaneous transcatheter closure of the PFO, which can be performed easily under light sedation by access through a vein in the groin.
In patients with migraine who undergo this procedure, the presence of aura, and of residual right-to-left shunt, appear to influence the amount of benefits, according to new data. As published in the February 10, 2020 issue of JACC, migraine symptoms were completely eliminated after PFO closure in nearly half of patients (48%), with this outcome being much more likely in patients with aura (OR 4.34; 95% CI 1.53-12.30), according to research led by Eyal Ben-Assa, MD (Tel Aviv Sourasky Medical Center, Israel, and Massachusetts General Hospital, Boston). Furthermore, the migraine symptoms were cut by more than half in 87.3% of patients. These improvements seemed to be even more likely in those cases where the PFO was completely closed, without evidence of a rest blood shunt after the intervention.
The authors concluded that there is a specific population that will benefit from PFO closure in terms of their migraines: for a person with the aura symptom, complete closure of the PFO should be attempted resulting in a higher likelihood that their migraines will improve.
The concept of PFO closure is not new. It is practised in patients who have suffered strokes and are found to have an open foramen ovale in order to prevent further strokes. Patients suffering from cardiac decompensation symptoms due to moderate-large shunts through the foramen ovale, will also need this intervention. What is new however, is the concept that the PFO closure has the potential to reduce or even eliminate migraine symptoms - a clear light on the horizon for any migraine sufferer!
Dr. Manuela Reisbeck, CardioCare Marbella, March, 2020
1. Ben-Assa E, Rengifo-Moreno P, Al-Bawardy R, et al. Effect of residual interatrial shunt on migraine burden after transcatheter closure of patent foramen ovale. J Am Coll Cardiol Intv. (JACC) 2020;13:293-302.
2. Liu K, Wang BZ, Hao Y, Song S, and Pan M. The correlation between migraine and patent foramen ovale. Front Neurol. Published online December 1, 2020. doi:10.3389/fneur.2020.543485