ISSN 0017-8748 0017-8748 ISSN doi: 10.1111/head.12618 10.1111/head.12618 doi: Published Inc. Published by by Wiley Wiley Periodicals, Periodicals, Inc.
Headache Headache C 2015 American Headache Society V © 2015 American Headache Society
Research Submission To Be or Not to Be Patent: The Relationship Between Migraine and Patent Foramen Ovale Nihan Kahya Eren, MD; Nazlı G. Bülbül, MD; Selcen Yakar Tülüce, MD; Cem Nazlı, MD; Yes¸im Beckmann, MD
Objective/Background.—Migraine is a common neurological disorder with an uncertain pathogenesis. A pathophysiological link has been proposed between the migraine headache and patent foramen ovale (PFO). However, the data about the association of migraine with the presence of PFO are conflicting. The study aims to prospectively investigate the prevalence of PFO in patients with migraine compared with that of control subjects. Methods.—A total of 203 migraineous patients and 212 control subjects with similar demographic characteristics to that of case subjects regarding age and gender were included in the study. Transthoracic echocardiography with agitated saline injection was used to evaluate the presence of PFO. PFO was judged to be present if any microbubble was seen in the left cardiac chambers within the first 5 cardiac cycles from the maximum right atrial opacification at rest or after provocative maneuvers. Results.—Mean age of the patients was 37.2 ± 9.8 years and 93% were female. Migraine with aura was present in 32% (n = 65) of the patients. The prevalence of PFO was similar in patients with migraine and the control subjects (42% vs 44%; odds ratio 0.90, 95% confidence interval 0.61-1.33, P = .61). Likewise, the prevalence of PFO was similar in migraineurs patients with or without aura (41% vs 42%; odds ratio 0.95, 95% confidence interval 0.51-1.76, P = .87). Conclusion.—This study suggest that PFO is not more common in patients with migraine compared with healthy subjects. Therefore, our findings suggest that the relationship between migraine headache and the presence of PFO is questionable. Key words: echocardiography, migraine, patent foramen ovale Abbreviations: CI confidence interval, MIST Migraine Intervention with STARFlex Technology, OR odds ratio, PFO patent foramen ovale, TIA transient ischemic attack
2015;55:934-942) (Headache 2015;••:••-••)
Migraine is a common, chronic neurovascular disorder characterized by recurrent and disabling
headache that can occur with or without aura and is often associated with a number of autonomic nervous system symptoms.1 A casual relationship has been hypothesized between migraine and patent foramen ovale (PFO). Several previous studies described a high prevalence of PFO in patients with migraine especially those with aura.2-5 Non-randomized interventional studies have suggested a beneficial role of percutaneous PFO closure in terms of frequency, intensity, and duration of migraine attacks.6-13 On the
From the Cardiology Department, Izmir Katip Celebi University Ataturk Education and Research Hospital, Izmir, Turkey (N. Kahya Eren, S. Yakar Tülüce, and C. Nazlı); Neurology Department, Izmir Katip Celebi University Ataturk Education and Research Hospital, Izmir, Turkey (N.G. Bülbül and Y. Beckmann). Address all correspondence to N. Kahya Eren, Cardiology Department, Izmir Katip Celebi University Ataturk Education and Research Hospital, Piri Reis Mah. I˙nönü Cad. No: 252/17, Konak, Izmir 35280, Turkey, email: [email protected]
Conflict of Interest: None. Accepted for publication May 1, 2015.
Financial Support: None.
934 1
Headache 2 other hand, the only randomized trial, the Migraine Intervention with STARFlex Technology (MIST) trial, has failed to show a significant benefit of percutaneous PFO closure on migraine attacks.14 Additionally, several recent large observational studies failed to demonstrate an association between migraine and PFO.15,16 Therefore, the prevalence and significance of PFO in patients with migraine are still not clearly known. The aim of this study was to investigate the prevalence of PFO in patients with migraine compared with that of control subjects.
METHODS The study population consisted of 203 consecutive patients followed and treated for migraine headache between January 2013 and May 2014 in our headache outpatient clinic. In addition, 212 healthy volunteers from hospital staff with similar demographic characteristics to that of case subjects regarding age and gender served as controls. The controls were evaluated during the same time period and had not been considered in other published analysis. The controls had a normal neurological examination and had not suffered from primary headaches. We conducted a detailed clinical evaluation in each patient, including a thorough neurological history, structured headache interview, and a detailed neurological examination. All interviews regarding the headache evaluation were conducted by at least 2 independent neurologists, and a consensus was reached after clinical deliberation among the authors. The headaches were diagnosed according to the International Classification of Headache Disorders of the International Headache Society 2013.17 The headache was characterized in a multidimensional manner to include the age of onset; description of the pain; temporal profile of pain onset; duration of headaches; location of the headache, perceived character, and severity of headache by the patient; usual time of occurrence of headache in a given day; whether headaches were aggravated by physical activity; family history of migraines; and finally, the headache triggers. The migraine attacks were classified according to the International Classification of Headache Disorders of the International Headache Society 2013.17 Headache
935 occurring on 15 or more days per month for more than 3 months, which has the features of migraine headache on at least 8 days per month, was classified as chronic migraine. The frequency of migraine attacks was also semiquantitatively classified as
Headache Headache C 2015 American Headache Society V © 2015 American Headache Society
Research Submission To Be or Not to Be Patent: The Relationship Between Migraine and Patent Foramen Ovale Nihan Kahya Eren, MD; Nazlı G. Bülbül, MD; Selcen Yakar Tülüce, MD; Cem Nazlı, MD; Yes¸im Beckmann, MD
Objective/Background.—Migraine is a common neurological disorder with an uncertain pathogenesis. A pathophysiological link has been proposed between the migraine headache and patent foramen ovale (PFO). However, the data about the association of migraine with the presence of PFO are conflicting. The study aims to prospectively investigate the prevalence of PFO in patients with migraine compared with that of control subjects. Methods.—A total of 203 migraineous patients and 212 control subjects with similar demographic characteristics to that of case subjects regarding age and gender were included in the study. Transthoracic echocardiography with agitated saline injection was used to evaluate the presence of PFO. PFO was judged to be present if any microbubble was seen in the left cardiac chambers within the first 5 cardiac cycles from the maximum right atrial opacification at rest or after provocative maneuvers. Results.—Mean age of the patients was 37.2 ± 9.8 years and 93% were female. Migraine with aura was present in 32% (n = 65) of the patients. The prevalence of PFO was similar in patients with migraine and the control subjects (42% vs 44%; odds ratio 0.90, 95% confidence interval 0.61-1.33, P = .61). Likewise, the prevalence of PFO was similar in migraineurs patients with or without aura (41% vs 42%; odds ratio 0.95, 95% confidence interval 0.51-1.76, P = .87). Conclusion.—This study suggest that PFO is not more common in patients with migraine compared with healthy subjects. Therefore, our findings suggest that the relationship between migraine headache and the presence of PFO is questionable. Key words: echocardiography, migraine, patent foramen ovale Abbreviations: CI confidence interval, MIST Migraine Intervention with STARFlex Technology, OR odds ratio, PFO patent foramen ovale, TIA transient ischemic attack
2015;55:934-942) (Headache 2015;••:••-••)
Migraine is a common, chronic neurovascular disorder characterized by recurrent and disabling
headache that can occur with or without aura and is often associated with a number of autonomic nervous system symptoms.1 A casual relationship has been hypothesized between migraine and patent foramen ovale (PFO). Several previous studies described a high prevalence of PFO in patients with migraine especially those with aura.2-5 Non-randomized interventional studies have suggested a beneficial role of percutaneous PFO closure in terms of frequency, intensity, and duration of migraine attacks.6-13 On the
From the Cardiology Department, Izmir Katip Celebi University Ataturk Education and Research Hospital, Izmir, Turkey (N. Kahya Eren, S. Yakar Tülüce, and C. Nazlı); Neurology Department, Izmir Katip Celebi University Ataturk Education and Research Hospital, Izmir, Turkey (N.G. Bülbül and Y. Beckmann). Address all correspondence to N. Kahya Eren, Cardiology Department, Izmir Katip Celebi University Ataturk Education and Research Hospital, Piri Reis Mah. I˙nönü Cad. No: 252/17, Konak, Izmir 35280, Turkey, email: [email protected]
Conflict of Interest: None. Accepted for publication May 1, 2015.
Financial Support: None.
934 1
Headache 2 other hand, the only randomized trial, the Migraine Intervention with STARFlex Technology (MIST) trial, has failed to show a significant benefit of percutaneous PFO closure on migraine attacks.14 Additionally, several recent large observational studies failed to demonstrate an association between migraine and PFO.15,16 Therefore, the prevalence and significance of PFO in patients with migraine are still not clearly known. The aim of this study was to investigate the prevalence of PFO in patients with migraine compared with that of control subjects.
METHODS The study population consisted of 203 consecutive patients followed and treated for migraine headache between January 2013 and May 2014 in our headache outpatient clinic. In addition, 212 healthy volunteers from hospital staff with similar demographic characteristics to that of case subjects regarding age and gender served as controls. The controls were evaluated during the same time period and had not been considered in other published analysis. The controls had a normal neurological examination and had not suffered from primary headaches. We conducted a detailed clinical evaluation in each patient, including a thorough neurological history, structured headache interview, and a detailed neurological examination. All interviews regarding the headache evaluation were conducted by at least 2 independent neurologists, and a consensus was reached after clinical deliberation among the authors. The headaches were diagnosed according to the International Classification of Headache Disorders of the International Headache Society 2013.17 The headache was characterized in a multidimensional manner to include the age of onset; description of the pain; temporal profile of pain onset; duration of headaches; location of the headache, perceived character, and severity of headache by the patient; usual time of occurrence of headache in a given day; whether headaches were aggravated by physical activity; family history of migraines; and finally, the headache triggers. The migraine attacks were classified according to the International Classification of Headache Disorders of the International Headache Society 2013.17 Headache
935 occurring on 15 or more days per month for more than 3 months, which has the features of migraine headache on at least 8 days per month, was classified as chronic migraine. The frequency of migraine attacks was also semiquantitatively classified as
