PFO closure

30 March 2017

PFO Closure for Migraine: An Update

James Discoveries & Stats, Information 9

12-14 years ago, there was a lot of discussion about “PFO closure” for migraine.

PFO stands for patent foramen ovale, a hole in the heart between the right and left chambers. A PFO is a common developmental condition, affecting about 1 in 4 people. But you may never know you have it.

patent foramen ovale Surgery can be done to close the PFO, for example if someone has low blood oxygen levels that may be caused by the defect. But years ago, patients who had the surgery for various reasons began to report that their migraine attacks had also subsided.

And so began the investigations and the trials. The well known MIST trials, originally planned as a series of four trials, were cancelled before the second one was completed. The results were not encouraging.

More studies have been done recently, and results continue to be mixed at best.

So why is PFO closure still being discussed? First, because some patients do experience a reduction in migraine symptoms after PFO closure. Second, it’s clear that migraine and PFO are somehow linked – PFO patients are much more likely to have migraine, and migraine patients are more likely to have PFO.

But a relationship does not mean that fixing one problem will fix the other, as trials have shown.

But there is more. For example, particles that move from one side of the heart to the other (through a shunt) may lead to migraine – not to mention the relationship between stroke, PFO and migraine. These particles in the blood may trigger a cortical spreading depression, a key part of the migraine chain-reaction.

In short, there are good reasons to think that PFO may actually increase migraine attacks.

So why doesn’t everyone with migraine just have the surgery? There are actually good reasons. And this has been one of the downfalls of the trials – patients simply don’t want to have heart surgery – even if it’s fairly simple surgery.

Though the surgery is generally safe, there are risks. In a report published earlier this month, PFO and Migraine: Is There a Role for Closure?, the authors noted that “several potentially life-threatening procedure-related adverse events occurred in the clinical trials”. There are also concerns that the surgery may lead to other health problems down the road.

Researchers remain intrigued by the possible connection between PFO closure and migraine. Although trials have been disappointing, it’s still worth trying to understand the connection, which may lead to other types of treatment. And it could be that we can find a certain type of migraine patient who will benefit from PFO closure, even if those are a small percentage of migraineurs.

But in the mean time, the poor chance of success, and risk of other health issues, and availability of many better treatments, continue to leave PFO closure in the area of research and not in the area of recommended treatments.

As the authors of the above say, although some patients who have the surgery for other reasons may see a decrease in migraine symptoms (either due to the closure or other reasons?), they “recommend against offering PFO closure as a preventive treatment for migraine”.

15 September 2014

Migraine Surgery – Should it be Banned?

James Information, News 2

The debate about migraine surgery is nothing new, but it shows no signs of going away. Researchers in Germany recently fired a shot at migraine surgeries, using strong words starting with the title of their editorial, published in the journal Cephalalgia, Surgical treatment for migraine: Time to fight against the knife.

Their article, which you can read for yourself, doesn’t hold back in criticizing treatments and studies that involve surgical intervention for migraine patients. They mention the dreaded word “placebo”, doubt if “treatment-refractory” migraine patients even exist (patients who don’t respond to treatment), conjure up images of Europeans gazing in horror at American websites about migraine treatments, and talk about the horrible effects that surgery can have.

Even if the authors of the article manage to offend just about everybody, their article should not be quickly ignored.

Sadly, there is an impression that when “all else fails” at least there’s a way to deal with the problem through surgery. Sure, it may be serious, but so is my pain.

But it’s not that simple. Surgery is no guaranteed cure for migraine (well, it’s not a cure at all – but there’s no guarantee that it will take the symptoms away), and surgery itself can cause more problems. And yes, those problems can be serious.

Authors Hans-Christoph Diener and Ulrike Bingel are right about one thing – the evidence for many – most migraine surgeries is not strong. Doctors are right to put surgery way at the bottom of the list of treatments to try for migraine.

There’s no doubt that many patients do not respond well to some migraine treatments. It takes many people many years to find a good treatment, if they find one at all.

But we can’t automatically assume that surgery is always out there, waiting to solve our problems once we’ve tried x number of medications.

Should we continue to study surgery as a migraine treatment? Many researchers think so, just as we should continue studying many migraine treatments. And no one that I know of is calling for a ban.

But we do need to take a closer look at the evidence before we recommend surgery to any patient. That means understanding the clinical trials, but also understanding the medical history of the patient, and taking time to understand which treatments have the best chance of working.

That’s what we all want, isn’t it?

Meanwhile, if you’re considering surgery for migraine, it’s worth your while taking a look at Diener and Bingel’s thoughts.

9 April 2011

In Children, the PFO Solution Studied

James Discoveries & Stats 0

Research continues on the option of PFO closure for people with migraine. As you may remember, studies in the past so far seem to show that we need to know more about which type of patients this may help. But this time, researched focused on children with migraine rekindles the debate.

PFO, or patent foramen ovale, has been the focus of a surgery that closes a common "hole in the heart". The question is – could closing this hole lead to relief from migraine?

Dr. Rachel McCandless led the team from the Primary Children’s Medical Center and the University of Utah to study the question. 109 children between the ages of 6 and 18 enrolled in the study. The researchers took two-dimensional echocardiograms of each child’s heart, looking for the PFO defect.

Of the children who had migraine without aura, about 25% of children had PFO – that reflects the % of the general population.

However, for children with migraine with aura, the % jumped to 50% – that’s double the general population. That also reflects the original numbers given early on in PFO-Migraine research.

Most likely, as with adult migraine patients, we need to learn more about the type of PFO that children have, and we need to correlate this with other health factors, before we can really know who to start treating. But the research is not dead – there seems to be a connection here. We just need more information to understand what it is.

For more on recent research into PFO and migraine, don’t miss Should we give up on the PFO Closure Solution? and from ScienceDaily Study Suggests a Relationship Between Migraine Headaches in Children and a Common Heart Defect.

23 February 2010

Should we give up on the PFO Closure Solution?

James News, Treatments 0

At one time, the PFO closure seemed like one of the most hopeful treatments for migraine. With a simple surgery, could your migraine attacks disappear?

PFO stands for patent foramen ovale, and the surgery closes a common "hole in the heart". When some patients getting the surgery reported that their migraine attacks had gone away, research was started to see if this treatment might hold the answer for a lot of migraineurs. (read more about what we said about PFO surgery in this edition of HeadWay back in 2003)

But the results of the research was unimpressive. Trials were cancelled. And patients started to look elsewhere.

But is this line of research dead? Should we be taking a closer look?

Researchers in the Department of Cardiology, University of Palermo (Italy) have decided to take a closer look, both at stroke patients and migraineurs who have PFO. The question is, what is their condition like? Not all PFO is the same – what if migraineurs with a certain type of PFO would benefit from surgery?

What the researchers did is compare migraineurs with patients with ischaemic stroke. Then they categorized the group by a couple of different factors – "embryonic recesses" and the severity and size of the PFO.

The results they found didn’t point obviously to which patients would benefit most from surgery, though the obvious answer would be those with the most severe PFO. However, it at least demonstrated the fact that both stroke and migraine patients varied quite a bit in a) whether or not they even had PFO (about 2/3 or migraineurs didn’t) and what type of PFO they had.

So the next step? Find out which patients benefit more from the simple surgery. What if, for example, 75% of patients with large PFO and migraine would find relief from surgery, while the others would not? It would be a big reason to avoid surgery in patients without severe PFO, and a big reason to give it a try in patients with severe PFO.

We’ll be watching for further research to tell us if PFO closure may still be promising for a large group of migraineurs.

Read about the study: The PFO anatomy evaluation as possible tool to stratify the associated risks and the benefits arising from the closure.