Online ISSN : 1687-8329

    




Quick Search 
 
Author  
Year    
Title  
Vol:  

 
 
January2008 Vol.45 Issue:        1        Table of Contents
Full Text
PDF


Migraine and Patent Foramen Ovale: Transesophageal Echocardiography Study. Should We Exclude Migraine without Aura?

Ashraf El-Mitwalli1, Abo Zaid Abd Allah2, Sherif Sakr3, Ahmed Azab1, Abdel Razik Maaty3
Departments of Neurology1, Cardiology3, Mansoura University; Neurology2, Benha University

ABSTRACT

Background and purpose: The prevalence and size of patent foramen ovale (PFO) in migraine without aura have never been assessed directly using Transesophageal echocardiography (TEE) and compared with migraine with aura. We sought to assess the prevalence and the size of patent foramen ovale in patients suffering from migraine with (MA) and without (MoA) aura using TEE. Methods: consecutive patients with migraine with and without aura were asked to participate in the study. Impact of migraine on daily life was assessed using the Migraine Disability Assessment (MIDAS) questionnaire.Contrast transesophageal echocardiography was performed to all participants and the presence of a patent foramen ovale and their size were assessed. Results: forty consecutive patients with migraine headache were included in our study. The majority of participants were women, mean age was 26.7 (18-38 year). Family history of migraine was encountered in 65% of patients. The mean Migraine severity using MIDAS was 16.2 (5-28) half of the patients were higher than the score of 21. Out of the 40 studied patients, 18 (45%) showed patent foramen ovale in TEE examination. Twenty patients (50%) had migraine with aura. There was no statistical difference between MA and MoA patients regarding age, sex, and MIDAS. The prevalence of patent foramen ovale was significantly higher in MA patients 11 out of 20 (55%) compared with 7 out of 20 (35%) MoA patients (OR 2.7, p=0.005). The presence of PFO was significantly related to the migraine disability severity score. Large PFO size was found in 45% of patients with MA while 42% of patients with MoA (p=NS). Conclusion: although prevalence of PFO is higher in migraine with aura, the prevalence of large PFO is nearly the same in both subtypes of migraine and more related to severity of migraine disability and family history of migraine.

INTRODUCTION

 

Migraine is a chronic, paroxysmal, neurovascular disorder that can start at any age and affects up to 6% of males and 18% of females in the general population1. With an estimated prevalence of 8 to 13% in the Western population, more than 55 million Europeans and Americans have migraine2,3. The most common right-to-left shunt in the adult population is a patent foramen ovale, a remnant of the fetal circulation and present in roughly a quarter of the general population4. It may be more frequent in the general population in the presence of migraine with aura than in subjects without migraine5. Whether this association is causally related with migraine is not known. Studies have suggested that migraine is independently associated with PFO among stroke patients6,7.

Many hypotheses could explain the etiology of migraines in those with a PFO, including right-to-left shunting of venous agents such as serotonin that are normally broken down in the pulmonary circulation8. Contrast echocardiography directly identifies cardiac shunts and indirectly distinguishes between cardiac and transpulmonary shunts. Transesophageal echocardiography is superior to the transthoracic approach for the diagnosis of intracardiac shunts9. Current treatment modalities are completely satisfactory in fewer than half of the patients1. As a new therapy for migraine headache, several studies showed a significant reduction in the prevalence of migraine with aura after percutaneous PFO closure6,10,11.

For many years migraine with aura was referred to as classic or neurologic migraine and migraine without aura as common migraine. The ratio of classic to common migraine is 1:512 and aura occurs in about 15% of migraineurs and does not occur in every attack. The prevalence and size of PFO in migraine without aura, which is commoner, have never been assessed directly using TEE and compared with migraine with aura. We sought to assess the prevalence and the size of patent foramen ovale in patients suffering from migraine with and without aura using Transesophageal echocardiography.

 

METHODS

 

Between November 2005and September 2006, consecutive patients with migraine with aura (MA) and without aura (MoA) consulting the Neurology Outpatient Clinic of Mansoura University Hospital or referring neurologists were asked to participate in the study.

The diagnosis of MA or MoA was based on the criteria adopted by the International Headache Society13. Diagnostic criteria for migraine with typical aura was done according to the International Classification of Headache Disorders, 2nd Edition (ICHD-2)14: (i) at least two attacks fulfilling criteria b-c; (ii) aura consisting of at least one of the following but no motor weakness: (a) fully reversible visual symptoms including positive features (i.e. flickering lights, spots, lines) and/or negative features (scotoma); (b) fully reversible sensory symptoms including positive features (i.e. pins and needles) and/or negative features (numbness); (c) fully reversible dysphasic speech disturbance; (iii) at least two of the following: (a)  homonymous visual symptoms and/or unilateral sensory symptoms; (b) at least one aura symptom developing gradually over ≥ 5 min and/or different symptoms occurring in succession over ≥ 5 min; (c) each symptom lasts ≥ 5 min and ≤ 60 min.

Patients with MoA who many years ago had once had a visual disturbance and were otherwise always MoA were classified as MoA patients. A non-aura reversible visual disturbance was considered in these patients. Migraine attacks had to be preceded by an aura on at least two occasions to be classified as MA. Isolated or single episodes of visual disturbance were not considered as MA.

Diagnosis of migraine with and without aura was established by at least two independent neurologists. Neurologists differentiate between MA and MoA were blinded to the presence of PFO also the cardiologists were blinded to the type of migraine. Informed consent was obtained from migraine patients.    

Impact of migraine on daily life was assessed using the Migraine Disability Assessment (MIDAS) questionnaire. The MIDAS score is the sum of missed work or school days, missed household chores days, missed non-work activity days, and days at work or school plus days of household chores where productivity was reduced by half or more in the past 3 months15.

Patients were eligible if they were ≥ 18 years, and had no contraindications for transesophageal echocardiography. Trans-esophageal echocardiography was performed using transesophageal phased array transducer, Model PEF-510 MA Toshiba model UIDM-400-A applications (2B 708-097E*C). The oropharynx was anesthetized using 10% lidocaine hydrochloride spray. Echo contrast tests (agitated normal saline) were performed in the transverse and longitudinal image plane by injection of 5 mL of contrast into an antecubital vein, followed by flushing with 10 mL of normal saline to fully opacify the right atrium.

Before the examination, all participants were coached to perform a Valsalva maneuver just before the injection with release on command after arrival of contrast medium in the right atrium. A leftward deviation of the interatrial septum in the fossa ovalis region after arrival of echo contrast was required as a sign of a successful Valsalva maneuver (i.e., increased right atrial preload leads to right atrial pressure increase), otherwise contrast application was repeated. The foramen ovale was considered patent if contrast bubbles crossed the septum within four cardiac cycles after full opacification of the right atrium. Late appearance of contrast bubbles after more than four beats in the left atrium was consistent with transpulmonary shunting. A right-to-left shunt was graded according to the number of bubbles crossing the septum within four cardiac cycles after full opacification of the right atrium: small if only a few bubbles (i.e., fewer than five bubbles) passed, moderate if a cloud of bubbles passed, and large if there was intense opacification of the left atrium16.

The presence of a patent foramen ovale or any other cardiac shunt and their size were assessed offline by two observers unaware of the participant's identity and study group. If tolerated, sedative medication (midazolam) was only administered after the contrast studies to complete the echocardiographic assessment of heart chambers, valves, and great vessels. All participants underwent a full transesophageal echocardiography study.

 

Statistical analysis:

It was performed using the Statistical Package for Social Sciences (SPSS computer program for windows, release 15; SPSS Chicago, IL, USA).  We compared normally distributed continuous data between participant groups by an unpaired two-tailed t test. Between-group comparisons of categorical data were performed with the Pearson χ2 test or the Fisher exact test for small (<10) cell counts. Values of p< 0.05 were considered to be statistically significant. 

RESULTS

 

Between November 2005 and September 2006, forty consecutive patients with migraine headache were included in our study. None of the participants had a history of lung disease, previous thromboembolic events, or other disorder potentially increasing right atrial pressure.

The majority of participants were women (75%), mean age was 26.7 (18-38 year). Family history of migraine was encountered in 65% of patients. The mean Migraine severity using MIDAS was 16.2 (5-28), half of the patients were higher than the score of 21(grade VI, severe disability). There was no statistical difference between MA and MoA patients regarding age, sex, and MIDAS (Table 1).

Twenty patients (50%) had migraine with aura, 16 (80%) with positive visual symptoms, 3 (15%) with negative visual symptoms and one (5%) with sensory symptoms. The other half had migraine without aura.

Out of the 40 studied patients, 18 (45%) showed patent foramen ovale in TEE examination.The prevalence of patent foramen ovale was significantly higher in MA patients 11 out of 20 (55%) compared with 7 out of 20 (35%) MoA patients (OR 2.7, p=0.005) (Table 2 and Fig. 1).

The presence of PFO was significantly related to the migraine disability severity score; out of the 11 MA patients with PFO, 10 patients had MIDAS above 21(OR 7.3, Exact Fischer test p=0.01) and out of the 7 MoA patients with PFO 6 patients had MIDAS above 21(OR 6.4, Exact Fischer test p=0.01). The same results were also applied for the presence of family history of migraine in both groups (not detected in the tables).

There was no significant statistical difference between MA and MoA patients regarding the large size patent foramen ovale; large PFO size was found in 45% of patients with migraine with aura while 42% of patients with migraine without aura showed large PFO (p>0.05) (not detected in the tables).

(Egypt J. Neurol. Psychiat. Neurosurg., 2008, 45(1): 75-82)

 





2008 � Copyright The Egyptian Journal of Neurology,
Psychiatry and Neurosurgery. All rights reserved.

Powered By DOT IT