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January2008 Vol.45 Issue:      1 Table of Contents
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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)

 




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).

Table 1. Patients characteristics.

 

p value

Migraine without Aura

n=20

Migraine with Aura

 n=20

 

0.60

26.2 (18-38)

27.3  (18-37)

Age, y

0.54

14 (70%)

16 (80%)

Female, n

0.38

13.7 (5-28)

18.8(6-27)

MIDAS

0.8

11(55%)

15 (75%)

Family history

MIDAS : Migraine Disability Assessment  questionnaire

 

Table 2. The transesophageal echocardiography results.

 

p value

Migraine without aura

n=20

Migraine with aura

n=20

 

0.005

7(35%)

11(55%)

PFO

0.81

3/7(42%)

5/11(45%)

Large shunt

18/40(45%)

Overall PFO

PFO : Patent foramen ovale

 

MA= Migraine with aura, MoA= Migraine without aura, PFO= patent foramen ovale.

Prevalence of PFO in MA was 55% and 35% in MoA p=0.005

 

Fig. (1): Prevalence of PFO in Migraine with and without aura.

 

 

 

Fig. (2): A 21 year old female with migraine without aura, longitudinal transesophageal contrast echocardiographic imaging in the midupper esophagus; showed slit-like septum with passage of a large amount of bubbles to the left atrium. right atrium (RA) and left atrium (LA).

 


 

DISCUSSION

 

We used transesophageal echocardiography (TEE) to directly assess the prevalence and size of patent foramen ovale particularly in migraine without aura which have never been assessed before using TEE comparing it with migraine with aura patients. In the present study, 45% of all migraineurs had PFO; more than third of migraine without aura (MOA) patients and more than half of migraine with aura (MA)  patients. The prevalence of large size PFO is the same in both MA and MoA patients. The presence of PFO in both subtypes is significantly related to the migraine severity and family history of migraine.

In the current study, the Overall prevalence of PFO is 45% in all migraineures, 55% in MA patients, 35%in MoA patients are similar to a previous study17 using transcranial Doppler sonography which was 41% in all migraineurs, 51.7% in MA, 33.7% in MoA patients and 20% in controls.

Dormitrz et al.18 assessed PFO in migraine patients and normal controls. The presence of PFO was found in 53% of MA patients compared with 25%MoA patients and 25% of control patients. In another study5 using Transcranial Doppler (TCD), PFO in MA patients was 48%, MoA 23% and 20% in controls. Moreover, Del Sette et al.19 performed a TCD study to assess the prevalence of PFO; it was 41% in MA patients and 8% in controls.

Schwerzmann et al.20 assessed 93 patients with migraine with aura and 93 healthy controls using transesophageal contrast echocardiography. A patent foramen ovale was present in 47% of patients with migraine with aura and 17% in controls. Moderate to large size PFO was 38% in MA patients and 7% in controls. These findings are in accordance with our study regarding MA patients. There was no TEE study directly evaluated the prevalence and size of PFO in MoA patients, However, the prevalence PFO in our study double that of the controls in that unique TEE study (35% in our MoA patients compared with 17% in their controls) and larger size of PFO in our MoA patients is significantly higher than their controls (42% compared with 7% in there controls). Moreover, prevalence of PFO in our MoA patients is still higher than that found in general population (9 to 26%) using TEE21,22, and slightly higher than the 27% in a large autopsy study4.

Patent foramen ovale closure is associated with a reduction in migraine Frequency and severity, as well as an improvement in MIDAS scores23,24. In the present study, the presence of PFO in both migraine subtypes is significantly related to the migraine disability severity score.

Whether the symptoms of migraine with aura are caused by ischemia is a controversial question25,26. Although a unified hypothesis for the pathogenesis of migraine is as yet unavailable, the relation between migraine severity and presence of PFO in both types MA and MoA migraine patients may be supported by Woods et al27 who suggested the possibility that blood flow changes may occur in migraine with and without aura, as the phenomenon of spreading oligemia had occurred in a patient with migraine without aura during positron emission tomography study.

It has been hypothesized that a particular genetic substrate might determine both atrial septal abnormalities and migraine. PFO and migraine can be inherited and transmitted simultaneously28. In our patients there is a significant relation between presence of PFO and family history of migraine  

It is often debated whether migraine with aura and migraine without aura are etiologically distinct disorders. A study using latent class analysis in Australian twins showed no evidence for separate subtypes of MOA and MA. These results do not support the MOA and MA subtypes as being etiologically distinct29.

Migraine with aura is more severe but not etiologically distinct from MO. In searching for predisposing genes, we should therefore expect to find some genes that may underlie all major recurrent headache subtypes, with modifying genetic or environmental factors that may lead to differential expression of the liability for migraine30.

In 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. It may be beneficial to include migraine without aura patients in prevalence studies using TEE and in PFO closure trials.  Larger randomized studies are needed to confirm these findings.

 

REEFRENCES

 

1.      Ferrari MD, Goadsby PJ. Migraine as a cerebral ionopathy with abnormal central sensory processing. In: Gilman S, ed. Neurobiology of Disease. New York, NY: Elsevier; 2006:333-348

2.      Henry P, Auray JP, Gaudin AF, et al. Prevalence and clinical characteristics of migraine in France. Neurology 2002;59:232–237.

3.      Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache 2001;41:646–657.

4.      Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984;59:17–20.

5.      Anzola GP, Magoni M, Guindani M, Rozzini L, Dalla VG. Potential source of cerebral embolism in migraine with aura: a transcranial Doppler study. Neurology 1999; 52:1622–1625.

6.      Azarbal B, Tobis J, Suh W, Chan V, Dao C, Gaster R. Association of interatrial shunts and migraine headaches: impact of transcatheter closure. J Am Coll Cardiol 2005;45: 489-492.

7.      Wilmshurst PT, Nightingale S, Walsh KP, Morrison WL. Clopidogrel reduces migraine with aura after transcatheter closure of persistent foramen ovale and atrial septal defects. Heart 2005; 91: 1173-1175.

8.      Adler E, Love B, Giovannone S, Volpicelli F, Goldman ME.  Correlation or causation: untangling the relationship between patent foramen ovale and migraine Curr Cardiol Rep. 2006 Mar;9(1): 7-12   

9.      Kerut EK, Norfleet WT, Plotnick GD, Giles TD. Patent foramen ovale: a review of associated conditions and the impact of physiological size. J Am Coll Cardiol 2001;38:613–623

10.    Mortelmans, K, Post, M, Thijs, V, et al The influence of percutaneous atrial septal defect closure on the occurrence of migraine. Eur Heart J 2005; 26, 1533-1537

11.    Slavin L, Tobis JM, Rangarajan K, Dao C, Krivokapich J, Liebeskind DS. Five-year experience with percutaneous closure of patent foramen ovale.
Am J Cardiol. 2007 May 1;99(9):1316-20.

12.    Adams R, Victor M, and Ropper A. Headache and Other Craniofacial Pains. In: Ropper AH and Brown RH (eds). Principles of Neurology 8th ed. New York: McGrow-Hill 2005:149.

13.    Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988; 7: 1-96.

14.    Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24 Suppl 1:9-160.

15.    Stewart WF, Lipton RB, Whyte J, et al. An international study to assess reliability of the Migraine Disability Assessment (MIDAS) score. Neurology 1999;53:988–994.

16.    Schuchlenz HW, Weihs W, Beitzke A, Stein JI, Gamillscheg A, Rehak P. Transesophageal echocardiography for quantifying size of patent foramen ovale in patients with cryptogenic cerebrovascular events. Stroke 2002;33:293–296.

17.    Carod-Artal FJ, da Silveira Ribeiro L, Braga H, Kummer W, Mesquita HM, Vargas AP. Prevalence of patent foramen ovale in migraine patients with and without aura compared with stroke patients. A transcranial Doppler study. Cephalalgia. 2006 Aug;26(8): 934-9.

18.    Domitrz I, Mieszkowski J, Kwiecinski H. The prevalence of patent foramen ovale in patients with migraine]. Neurol Neurochir Pol 2004; 38: 89-92.

19.    Del Sette M, Angeli S, Leandri M, Ferriero G, Bruzzone GL, Finocchi C, Gandolfo C. Migraine with aura and right to- left shunt on transcranial Doppler: a case–control study. Cerebrovasc Dis 1998; 8:327–30.

20.    Schwerzmann M, Nedeltchev K, Lagger F, Mattle HP, Windecker S, Meier B, Seiler C. Prevalence and size of directly detected patent foramen ovale in migraine with aura. Neurology. 2005 Nov 8;65(9):1415-8.

21.    Agmon Y, Khandheria BK, Meissner I, et al. Comparison of frequency of patent foramen ovale by transesophageal echocardiography in patients with cerebral ischemic events versus in subjects in the general population. Am J Cardiol 2001; 88:330–332.

22.    Fisher DC, Fisher EA, Budd JH, Rosen SE, Goldman ME. The incidence of patent foramen ovale in 1,000 consecutive patients: a contrast transesophageal echocardiography study. Chest 1995;107:1504–1509.

23.    Reisman M, Christofferson RD, Jesurum J, Olsen JV, Spencer MP, Krabill KA, Diehl L, Aurora S, Gray WA. Migraine headache relief after transcatheter closure of patent foramen ovale.J Am Coll Cardiol. 2005 Feb 15; 45(4):493-5.

24.    Kimmelstiel C, Gange C, Thaler D. Is patent foramen ovale closure effective in reducing migraine symptoms? A controlled study. Catheter Cardiovasc Interv. 2006 Apr 1;69(5):740-6.

25.    Skyhoj Olsen T, Friberg L, Lassen NA. Ischemia may be the primary cause of the neurologic deficits in classic migraine. Arch Neurol 1987; 44: 156-161.

26.    Dalgaard P, Kronborg D, Lauritzen M. Migraine with aura, cerebral ischemia, spreading depression, and compton scatter. Headache 1991; 31: 49-53.

27.    Woods RP, Iacoboni M, Mazziotta JC. Brief report: bilateral spreading cerebral hypoperfusion during spontaneous migraine headache. N Engl J Med. 1994 Dec 22; 331(25):1689-92.

28.    Wilmshurst PT, Pearson MJ, Nightingale S, Walsh KP, Morrison WL. Inheritance of persistent foramen ovale and atrial septal defects and the relation to familial migraine with aura. Heart 2004; 90:1315–20.

29.    Ligthart L, Boomsma DI, Martin NG, Stubbe JH, Nyholt DR. Migraine with aura and migraine without aura are not distinct entities: further evidence from a large Dutch population study. Twin Res Hum Genet. 2006 Feb;9(1):54-63.

30.    Nyholt DR, Gillespie NG, Heath AC, Merikangas KR, Duffy DL, Martin NG. Latent class and genetic analysis does not support migraine with aura and migraine without aura as separate entities. Genet Epidemiol. 2004 Apr;26(3):231-44.

 

الملخــص العربـــى

 

الموجات الصوتية على القلب عبر المريء فى مرضى الشقيقة المصحوب

وغير المصحوب بالنسمة

 

أثبتت الدراسات وجود ثقب بين الأذينين فى مرضى الشقيقة المصوبة بالنسمة بصوره ذات دلاله إحصائية مقارنة بالأصحاء وأن غلق هذا الثقب قد يقلل من تكرار وحدة نوبات الشقيقة. لم يسبق عمل دراسة باستخدام الموجات الصوتية على القلب عبر المريء فى مرضى الشقيقة الغير مصحوبة بالنسمة مع انه يمثل خمسة أضعاف مرضى الشقيقة المصحوبة بالنسمة . ويهدف البحث دراسة الثقب بين الأذينين فى مرضى الشقيقة الغير مصحوبة بالنسمة ومقارنة وجود وحجم هذا الثقب بوجوده وحجمه فى مرضى الشقيقة المصحوبة بالنسمة. أجريت الدراسة على 40 مريضا بالشقيقة- نصفهم مصاب بالشقيقة الغير المصحوبة بالنسمة- تم فحصهم إكلينيكيا كما أجرى لهم اختبار مقياس شدة الشقيقة وتم إجراء موجات صوتية على القلب عبر المريء لجميع المرضى.

وقد أظهرت النتائج وجود هذا الثقب فى أكثر من نصف مرضى الشقيقة المصحوبة بالنسمة وأكثر من ثلث مرضى الشقيقة الغير مصحوبة بالنسمة ولكن لم يكن هناك فرق ذو دلالة إحصائية بين المجموعتين بالنسمة لكبر حجم هذا الثقب. وجد أيضا علاقة ايجابية ذات دلاله إحصائية بين وجود هذا الثقب وشدة الشقيقة وأيضا مع وجود مصابين آخرين بالشقية فى أسر المرضى. ونخلص من هذا البحث أن وجود وكبر حجم الثقب بين الأذينين فى مرضى الشقيقة الغير مصحوبة بالنسمة أكثر بصورة داله إحصائيا عن الأصحاء فى الدراسات التى استخدمت الموجات الصوتية على القلب عبر المريء ولا يجب استثناءهم من الدراسات باستخدام هذه الوسيلة الأدق ويمكن أيضا استفادتهم من غلق هذا الثقب عبر القسطرة خاصة الذين يعانون من نوبات شديدة تؤثر على أنشطتهم اليومية ولا يستجيبون للأدوية حتى الحديث منها.

 



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