Impact of Percutaneous Closure of Interatrial Shunts on Migraine Attacks: Single-Operator Series and Review of the Literature

Abstract

Background: The association of migraine with intracardiac communications and a resultant improvement with their closure has been a matter of controversy. Mostly observational and retrospective studies indicate a significant improvement in migraine attacks in patients undergoing percutaneous closure procedures. However, there is a paucity of randomized trials on this topic and prospective data provide little evidence that the device closure approach has any significant effect on migrainous attacks.

Objective: The aim of this study is to further examine this important controversial topic by presenting our own prospective findings from a single-operator series of 110 patients with patent foramen ovale (PFO) or atrial septal defect (ASD) undergoing percutaneous device closure and also by conducting an in-depth literature review, amply discussing the data on this topic and finally proposing a practical strategy for migraineurs.

Methods: A prospective analysis of our own data was conducted among 110 patients undergoing percutaneous closure of either a patent foramen ovale (PFO) (n=75) or an atrial septal defect (ASD) (n=35), investigating the impact of PFO/ASD closure on migraine symptoms. Closure was effected with use of an Amplatzer occluder in a simplified procedure, performed under local anesthesia with use of plain fluoroscopy alone without intra-procedural echocardiographic guidance. Complete sealing was obtained in 98.7% of PFO patients and 94.3% of ASD patients. All patients were questioned about migraine symptomatology and were followed-up long-term for their clinical outcome. They all received dual antiplatelet therapy for 6 months.

Results: Great improvement in migraine symptomatology was observed after the closure procedures. Specifically, 54 (49%) patients suffered from migraine before the procedures, 45 PFO and 9 ASD patients. Improvement (50%) or abolition (33.3%) of migraine symptoms occurred in 45 patients, 37 (82.2%) PFO and 8 (88.9%) ASD patients, yielding an overall favorable effect of 83.3%. An atrial septal aneurysm was present in 44 (58.7%) PFO patients, which has recently been considered an important predictor of the occurrence of migraine in PFO patients. Importantly, the favorable effect extended beyond the 6-month period when dual antiplatelet therapy was discontinued. A recent comprehensive meta-analysis of 20 studies, comprising patients with unexplained stroke and migraine undergoing transcatheter PFO closure, showed that resolution of migraine occurred in a majority of patients with aura and for a smaller proportion of patients without aura. On the other hand, another recent review maintains that closure of PFO for migraine prevention does not significantly reduce the intensity and severity of migraine.

Conclusion: A high percentage (49%) of PFO/ASD patients in this series were also migraine sufferers. Percutaneous closure offered migraine relief in 83% of patients, 82% in PFO patients and 89% in ASD patients. Thus, based on this experience and on literature review, a strategic approach for device closure is proposed for migraineurs with a PFO or ASD.

Keywords: Amplatzer occlude; atrial septal defect; interatrial shunts; migraine; patent foramen ovale; percutaneous cardiac defect closure.