Migraine headaches associated with patent foramen ovale

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Overview.

A type of migraine that may be associated with cardiac patent foramen ovale often presents with typical migraine symptoms such as severe headache, nausea, vomiting, preictal flashes of light, and visual distortions The first visit to a neurologist is usually recommended, and cardiology may be indicated when necessary In addition to conventional medications, patent foramen ovale blockage may be performed, but the effectiveness of the procedure is controversial

Definition

  • Foramen ovale occludens-associated migraine refers to a condition in which the onset of migraine in certain migraine patients may be associated with a patent foramen ovale occludens (PFO) of the heart.
  • Migraine is the most common primary headache and is associated with chronic neurovascular dysfunction.
  • Foramen ovale failure is a developmental abnormality in which the foramen ovale between the right and left atria fails to close on time after birth.
  • Some studies have suggested that there may be a link between patent foramen ovale and migraine, especially in migraine patients with aura manifestations such as flashes of light and visual distortions before the headache (migraine with aura). However, the exact intrinsic link and mechanism are not clear [1-3].

    • Morbidity

  • There are no data on the incidence of migraine associated with patent foramen ovale.
  • However, some studies have shown that the prevalence of migraine in China is about 9.3 per 100 people, and the prevalence of patent foramen ovale unenclosed in migraine patients is as high as 39.8% to 72%. Migraine with aura accounts for about 10% of all migraine patients [1].

    • Etiology

    Pathogenesis

    The foramen ovale is a small hole located between the right and left atria of the heart that usually closes naturally after birth. However, in some populations, the foramen ovale fails to close completely, causing blood to flow from the right atrium into the left atrium, creating what is known as a right-to-left shunt (RLS).

    The occurrence of certain migraine headaches may be associated with an unclosed foramen ovale, but it is not yet clear [3-4], and the following is evidence of a link between an unclosed foramen ovale and migraine headaches:

  • The prevalence of foramen ovale insufficiency in migraine patients can be as high as 39.8% to 72%, which is much higher than that of the general population.
  • The prevalence of RLS is much higher in migraine patients with aura than in the normal population.
  • RLS blood flow is significantly higher in patients with migraine than in those without migraine. And the higher the RLS blood flow, the higher the prevalence.
  • In migraine patients with aura, surgery to block the foramen ovale can be effective in reducing headache symptoms.

    • Triggers

    The following factors can trigger migraine attacks [3-4].

  • Diet: hunger or eating special foods such as cheese, meat and pickles, chocolate, wine.
  • Drugs: oral contraceptives, vasodilators such as nitroglycerin.
  • Mental factors: stress, anxiety, depression, tension.
  • Sleep: insufficient or excessive sleep.
  • Behavior: painful crying, overwork, strenuous exercise.
  • Special stimuli: bright light, noise, odor, climate change.

    • Pathogenesis

    The mechanism of migraine caused by patent foramen ovale unenclosure is not completely clear, but there are two main doctrines: the paradoxical embolism hypothesis and the vasoactive substance hypothesis [4-6].

    Paradoxical embolism hypothesis

    The paradoxical embolism hypothesis suggests that an unclosed foramen ovale can cause substances such as blood clots to bypass the pulmonary circulation and go directly to the cerebral arteries, triggering a transient occlusion of the arteries in the brain.

    This causes an electrical stimulation of the cerebral cortex, which subsequently triggers cortical spreading depression (CSD).

    CSD causes changes in vasodilatation, leading to ischemia in some areas and causing migraine attacks.

    Vasoactive substance hypothesis

    The vasoactive substance hypothesis suggests that the enzyme monoamine oxidase (MAO) in the lungs degrades vasoactive substances in the blood, such as substance P (SP) and calcitonin-derived gene-related peptide (CGRP).

    Venous blood in patients with patent foramen ovale may not pass through the pulmonary circulation, allowing these substances to enter the intracerebral arteries directly without being degraded.

    Increased levels of CGRP and SP stimulate intracranial pain-sensitizing structures, triggering symptoms such as headaches and muscle tension and leading to neurogenic inflammation.

    This inflammation, in turn, further promotes activation and sensitization of trigeminal injury receptors, leading to persistent headaches.

    In addition, studies have suggested that abnormal platelet activation due to RSL is also associated with the disease.

    Symptoms.

    It often presents with typical migraine symptoms such as severe unilateral headache, nausea, vomiting, and sensitivity to light, sound, and odor. Some patients may experience aura symptoms such as flashes of light and visual distortion prior to an attack.

    Main Symptoms

    A typical migraine attack is categorized into the following four phases, but symptomatic changes and attack frequency vary widely between patients [1-3].

    Prodromal phase

    Twenty-four to 48 hours, or even a few days, before a migraine attack, some patients may have some prodromal manifestations.

  • Yawning and lack of concentration.
  • Mood changes, from depression and loss to excitement, or from excitement to loss and irritability.
  • Thirst, loss of appetite.
  • Increased urination, constipation.
  • Stiff neck.

    • Aura period

    Some neurologic symptoms, called aura symptoms, may briefly appear before, or during, a headache attack. These appear gradually 5 to 20 minutes before the attack and last no more than 60 minutes.

    Visual aura is the most common, followed by sensory aura, verbal and motor aura are rare, and different auras may appear one after the other.

    Visual aura
  • Flashes of light and dark spots may appear before the eyes.
  • Commonly, these are zigzag and wavy line flashes of light that gradually expand to the periphery.
  • Blurred vision (not being able to see clearly).
  • Inability to see out of one eye (blindness) and inability to see out of one eye or one side of both eyes (visual field defect).
    • Sensory aura

    Numbness on one side of the body, face, or tongue, with a slow-moving pins and needles sensation that gradually becomes larger or smaller.

    Speech aura

    Such as slurred speech and labored speech.

    Motor aura

    Weakness of one side of the arms, legs, or facial muscles.

    Seizure

    Typical symptoms
  • Most headaches are located on one side of the head, extending from one temple to the entire head on the same side, and may also shift from one side to the other.
  • Mostly throbbing headache (throbbing pain), but also can be manifested as pins and needles or swelling pain, which can last for 4 to 72 hours.
  • The headache can be aggravated by bending over, lowering the head, coughing, sneezing, walking up and down stairs, and physical activity.
  • Headaches may be relieved by being in a quiet or dark environment, after vomiting, or after sleep.
    • Accompanying symptoms
  • Nausea, vomiting, vertigo.
  • Particular sensitivity to strong light, certain sounds, and odors.
  • Pale skin.
  • Emotional instability and irritability.

    • Recovery period

    Fatigue, lethargy, irritability, weakness and poor appetite are often present after the headache is relieved, and can often be improved after 1 to 2 days.

    Other symptoms

    Ovarian aperture unclosure can cause symptoms of cardiac dysfunction, common manifestations are as follows.

  • Dizziness, unexplained fainting.
  • Apnea (more than 10 seconds) during sleep.
  • Dyspnea when lying down.

    • Complications

    The following conditions may occur in some patients during the course of the disease [3-4].

    Migraine persistence

    Migraine attacks lasting ≥ 72 hours and with severe pain that is only briefly relieved by sleep or medication and not completely terminated.

    Migraine cerebral infarction

    Migraine with aura is characterized by the presence of one or more of these aura symptoms during an attack that lasts more than 1 hour and by cranial magnetic resonance or CT examination that reveals a cerebral infarct lesion.

    Persistent aura without infarction

    Migraine with aura presents with one or more of the aura symptoms in a single attack that lasts more than 1 week, but no cerebral infarct lesion is detected on imaging.

    Migraine aura-induced epileptic seizures

    In rare cases, migraine aura symptoms can trigger an epileptic seizure, which manifests as a sudden jerking of the body or even fainting. Epileptic seizures most often occur during or within 1 hour after the aura symptoms.

    Consultation

    Department of Medicine

    Neurology

    Patients with severe unilateral headache, nausea, vomiting, and sensitivity to light, sound, and odor should seek medical attention. Some patients may experience aura symptoms such as flashes of light and visual distortion before the attack.

    Cardiology, Cardiac Surgery

    If chest tightness, shortness of breath, palpitations, or weakness occurs after activity or exertion, seek medical attention as soon as possible.

    Preparation for medical treatment

    Preparing for your visit: registering, preparing your documents, FAQs

    Tips

    Avoid self-medicating with painkillers before going to the doctor to avoid aggravating the symptoms or masking the condition.

    If you usually keep a headache diary, you can give it to the doctor when you visit the doctor for more reference.

    Preparation List

    Symptom list

    Especially focus on the time of onset of symptoms, special manifestations, etc.

  • What are the characteristics of the headache? Include the location, nature (dull, sharp, throbbing), degree and duration of pain.
  • Is the migraine attack accompanied by nausea, vomiting, sensitivity to light or sound?
  • Are aura symptoms such as visual flickering, visual field loss, or other sensory abnormalities experienced prior to the headache attack?
  • Describe the frequency of migraine attacks and whether daily activities were affected during the attacks.
  • When did these manifestations occur? Did they get progressively worse?
    • Medical History Checklist
  • Are there other migraineurs in the family?
  • Are there any underlying medical conditions such as heart disease, high blood pressure or diabetes?
  • What triggers precede the onset? Including special diets, medications, psychiatric factors, etc.?
  • Has it been previously diagnosed and treated? How was it treated?
    • Checklist

    Test results from the last six months to bring with you to the doctor’s office

    Echocardiogram, cranial MRI or CT scan, etc.

    List of medications used

    Medication used in the last 3 months, if available in boxes or packages, bring with you to the doctor’s office

  • Acetaminophen, ibuprofen, naproxen, diclofenac sodium, aspirin, etc.
  • Sumatriptan, zolmitriptan, rizatriptan, bupropion, etc.

    • Diagnosis

    Diagnosis is based on

    Medical history

  • The patient has a history of patent foramen ovale and may have a family history of migraine.
  • Headache attacks may be preceded by associated triggers, including diet, medications, psychogenic factors, sleep, behavior, and specific stimuli.

    • Clinical manifestations

    Symptoms

    It often presents with typical migraine symptoms, such as severe unilateral headache, nausea, vomiting, sensitivity to light, sound and odor. Some patients may have aura symptoms such as flashes of light and visual distortion before the attack.

    Physical signs

    For patients with migraine symptoms, the doctor will perform a cardiac auscultation test, and some patients may hear a heart murmur or a split second heart sound.

    Imaging

    Common tests include echocardiograms, imaging tests and angiograms.

    Echocardiography

    The presence of right-to-left shunting can be assessed according to the number of microbubbles in the left heart and arteries [5-8].

  • Transesophageal echocardiography (TEE) and transesophageal echocardiographic acoustic angiography (cTEE) are the gold standard and preferred method to confirm the diagnosis of the disease. It can clarify the morphology, location, and concomitant defects of the unclosed foramen ovale. However, patients experience some discomfort during the examination and it cannot be used for screening.
  • Transthoracic echocardiography (TTE) and transthoracic echocardiographic acoustic contrast (cTTE) are commonly used tests to detect the presence of patent foramen ovale. The examination is quick and less painful. However, it is not as sensitive as transesophageal echocardiography, and it is sometimes difficult to accurately measure the size of the diameter of the unclosed foramen ovale.
  • Transcranial Doppler ultrasound acoustic contrast (cTCD), also known as contrast-enhanced TCD and TCD foam test, monitors the number of microbubbles in the intracranial arteries and evaluates right-to-left shunting. The disease may be suspected when a right-to-left shunt is found.
    • CT or magnetic resonance imaging (MRI) examination

    CT or magnetic resonance imaging (MRI) can show the structure and size of the heart and blood vessels, and can be used to find out whether there are other malformations of the heart and large blood vessels, and is a complementary means of diagnosis.

    Cardiac catheterization and cardiovascular angiography

    Cardiac catheterization and cardiovascular angiography is an interventional technique in which a thin, flexible catheter is delivered to the heart and large blood vessels through the arteries in the groin and arms. Unclosed patent foramen ovale can be directly visualized. It is rarely used for diagnosis alone and is usually accompanied by blockage therapy.

    Differential diagnosis

    In the presence of an unclosed foramen ovale, disorders that can cause headaches on one side are easily confused with this condition. Common examples are temporal arteritis, cluster headaches, and tension headaches [1-3].

    Temporal arteritis

    Temporal arteritis usually occurs in patients over 50 years of age and is characterized by bilateral temporal pain that is persistent.

    Patients may present with increased pain with chewing, scalp pressure, and hardening or swelling of the temporal arteries.

    Systemic symptoms such as elevated body temperature, fatigue, and loss of appetite may also be present.

    Cluster headache

    Cluster headache pain is usually located around or behind the eyes and is of short duration, usually between 15 minutes and 3 hours.

    The attacks are distinctly periodic, usually occurring at night, and the pain is intolerable and may be accompanied by autonomic symptoms such as tearing, nasal congestion, and facial sweating.

    Tension Headache

    Tension headaches are usually characterized by a dull ache or a tightening sensation, and the pain often affects the entire head, with little impact on daily life.

    Treatment

  • Aim of treatment: There is no cure for this disease, and the treatment mainly focuses on pain relief, symptomatic relief and improvement of quality of life.
  • Treatment principle: In addition to conventional medication, oval foramen occlusion can be performed, but the effectiveness of the surgery is controversial.

    • General treatment

  • When migraine attacks occur, use the following methods to help relieve the headache.
  • Rest or sleep in a dark, quiet room.
  • Wrap an ice pack in a cloth and place it on the back of the neck and gently press on the painful area.

    • Medication

    Commonly used medications include those that relieve headache symptoms and those that prevent headache attacks [1-3].

    Treatment during an attack

    The use of medication provides rapid and sustained analgesia, reduces headache recurrence, and restores normal living conditions. Commonly used drugs are as follows [1-3].

    Analgesic drugs
    Commonly used medications for pain levelMild-moderate Acetaminophen, ibuprofen, naproxen, diclofenac, aspirin, and combinations of caffeine are most widely used. Acetaminophen is indicated for people who are allergic or intolerant to aspirin or other NSAIDsMild-moderate
    Acetaminophen, ibuprofen, naproxen, diclofenac, combinations of aspirin and caffeine are the most widely used.
    Most widely used. Acetaminophen is indicated for those who are allergic or intolerant to aspirin or other NSAIDsModerate-to-severe sumatriptan, zolmitriptan, rizatriptan, ergotamine tartrate, dihydroergotamine, and bupropion can be used at any time of the headache except during the aura phase, and the earlier they are applied, the more effective they are. Ergot and treprostinil should not be used more than 2-3 days per week to avoid overdose headache.Moderate to severe

    Sumatriptan, zolmitriptan, rizatriptan, ergotamine tartrate, dihydroergotamine, bupropion, etc.

    Can be used at any time of the headache except during aura, the earlier the application the better the result. Ergot and Triptans should not be used more than 2-3 days per week to avoid overdose headache.

    Other drugsTypes of Drugs Commonly Used Drugs Instructions for UseAntiemetic drugs metoclopramide, domperidone, etc. to relieve nausea and vomiting symptoms, and facilitate the absorption of other drugsAntiemetic drugsMetoclopramide, domperidone, etc.Relieve nausea and vomiting symptoms and facilitate the absorption of other drugs.Sedative drugs benzodiazepines, barbiturates sedatives have the effect of sedation, lead to sleep, but there is a certain degree of addiction, only for other drugs to treat the failure of serious patients

    Sedative drugs

    Benzodiazepines, barbiturates sedatives

    Have the effect of sedation, guide to sleep, but have a certain degree of addiction, only for other drug treatment is ineffective in serious patients

    Preventive treatment

    Prophylactic treatment refers to the use of medication to prevent headache attacks when they have not yet occurred, commonly used medications are listed below.

    Drug Class Drug Name Instructions for Use

    Non-steroidal anti-inflammatory drugs such as naproxen and ibuprofen should not be used for a long period of time or in large quantities, and should not be used for pain relief for more than 5 days.

    Non-steroidal anti-inflammatory drugs

    Naproxen, Ibuprofen, etc.

    Should not be used for a long time or in large quantities, and should not be used for pain relief for more than 5 days.

    Beta-blockers propranolol, metoprolol, timolol, atenolol, bisoprolol, etc. may reduce the frequency and severity of migraine headaches.

    Beta-blockers.

    Propranolol, metoprolol, timolol, atenolol, bisoprolol, etc.

    May reduce the frequency and severity of migraine headaches.

  • Calcium antagonists verapamil, flunarizine, etc. may prevent migraine attacks and relieve symptoms
  • Calcium antagonists
  • Verapamil, Flunarizine, etc.
  • May prevent migraine attacks and relieve symptoms
  • The antidepressant amitriptyline reduces the frequency of migraine headaches

    • Antidepressants

    Amitriptyline

    Reduce the frequency of migraine

  • Antiepileptic drugs valproate, topiramate, and gabapentin Sodium valproate may cause nausea, tremors, weight gain, hair loss, and liver function abnormalities; topiramate may cause weight loss, drowsiness, and poor concentration
  • Antiepileptic drugs
  • Valproate, topiramate, gabapentin, etc.

    • Valproate may cause nausea, tremor, weight gain, hair loss and liver dysfunction; topiramate may cause weight loss, drowsiness and poor concentration

    The 5-hydroxytryptamine receptor antagonist phenothiazine may reduce vasospasm, inflammatory response, and decrease pain sensitivity.

    5-hydroxytryptamine receptor antagonist

  • Phenothiazine
  • Decreases vasospasm, inflammatory response, and reduces pain sensitivity.

    • Surgery

    For migraine triggered by patent foramen ovale unenclosed, some studies have suggested that PFO occlusion is an effective treatment, but there is no authoritative conclusion, and the risks of surgery should not be ignored [6-8].

    Purpose of surgery

  • Surgery can close the foramen ovale and reduce or eliminate migraine.
  • Indications for surgery

    • It is mainly used for migraine patients with aura.

  • Surgical results
  • Many studies have found that PFO closure can significantly reduce the number and duration of migraine attacks. Approximately 40% of migraineurs with aura experience a significant reduction in symptoms.
  • Risks of surgery

    • There is a risk of infection, arrhythmia, cardiac perforation and blocker thrombosis, with atrial fibrillation being the most common complication.

  • Post-operative precautions
  • Oral medications such as warfarin, aspirin, and clopidogrel are usually required after surgery, but there is controversy over the dosage and use of the medications.
  • Other treatments
  • For migraine, traditional Chinese medicine (TCM), psychology, electrical nerve stimulation, nerve block and other treatments can also be used [1-3].

    • Chinese medicine treatment: Chinese medicine categorizes migraine as head wind and cerebral wind, and uses traditional Chinese medicine, acupuncture and tuina to relieve headache. Be sure to receive treatment in a regular medical institution and do not blindly trust migraine prescriptions.

    Psychotherapy: Through relaxation therapy, biofeedback and cognitive therapy, the body and mind can be regulated to reduce stress reactions and relieve headaches.

  • Nerve electrical stimulation therapy: through electrical stimulation of peripheral nerves, such as transcutaneous supraorbital nerve stimulation, transcranial magnetic stimulation and other methods, to treat pain in the innervated area. It has better efficacy and safety.
  • Peripheral nerve block therapy: through the pterygopalatine ganglion nerve block method, anesthetic is sprayed into the nasal mucosa to relieve chronic migraine.

    • Cutting-edge treatment: Calcitonin gene-related peptide (CGRP) inhibitors such as Erenumab, Fremanezumab and Galcanezumab are new migraine treatment drugs that are not yet available in China.

  • Prognosis
  • Cure

    • There are no authoritative prognostic data for migraine associated with patent foramen ovale unenclosed [1-3,8].

    Migraine cannot be cured and does not heal on its own.

  • Foramen ovale agenesis is usually a congenital condition and does not usually close naturally.
  • Most migraineurs have a favorable prognosis. Migraine symptoms may gradually resolve with age, and some patients may be migraine-free by the age of 60 to 70 years.
  • Prognostic factors
  • Younger patients and those without serious complications have a relatively good prognosis. In the course of treatment, measures such as following medical advice, adjusting lifestyle habits, and actively cooperating with treatment can help to improve the therapeutic effect and improve the prognosis.
  • Harmfulness
  • Migraine is a disabling neurological disorder. Long-term recurrent severe headache will significantly reduce the patient’s life, work and socialization, and will also bring serious economic and social burdens to individuals and families.