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
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.