Patent foramen ovale closure and migraine: science and sensibility

Figures & data

Table 1. Characteristics of migraine versus limitations of the patent foramen ovale–paradoxical embolism–migraine theory.

Migraine	PFO–PE–migraine theory
Headache attacks are cyclical and predictable in most patients, particularly in menstrual migraine [69,73]	Completely unpredictable phenomenon
Headache attacks usually lateralize over several decades (unilateral or bilateral) [69,73]	No plausible explanation
Characteristic migraine-related prodrome with significantly delayed (several hours or few days) onset of attacks [49,69,73]	No plausible explanation
Incidence of migraine F:M ≥2:1 [69]	No gender trend for PFO [72]
Migraine attacks usually do not begin at birth; characteristic remissions and exacerbations occur during the life of a patient [69,73].Migraine generally subsides with advancing age	Congenital defect present from birth; enlarges with age [67,72].PFO–PE theory cannot explain the frequent onset of migraine attacks in second/third decade, or sustained spontaneous remissions/exacerbations or the ‘protective’ effect of aging
‘Protective’ effect of LRS in ASD [4,29]. Closure of ASD can immediately precipitate or aggravate migraine	No such protection can be envisaged. Effective ASD/PFO closure precludes PE
‘Protective’ effect of stress [49]	No such protection can be envisaged
‘Protective’ effect of sustained systemic excess of 5-HT [70,71]	No such protection can be envisaged
‘Protective’ effect of estrogens [73,76]	No rational explanation. Estrogens activate platelets and promote thromboembolism
Propranolol frequently prevents migraine but aggregates platelets [74]	No rational explanation
Propranolol, as well as atenolol, do not affect brain circulation significantly. Atenolol does not influence brain neuronal function, but is as effective as propranolol in preventing migraine [16]	No rational explanation. No migraine preventive pharmacological agent affects PFO size or closure
Aspirin inhibits platelet aggregation but does not prevent migraine in controlled studies [75]	No rational explanation
Migraine-related stroke is rare and mainly affects younger women [81,82]	No rational explanation for rarity or for age/gender trend for stroke development in migraine patients

5-HT: 5-hydroxytryptamine; ASD: Atrial septal defect; F: Female; LRS: Left-to-right shunt; M: Male; PE: Paradoxical embolism; PFO: Patent foramen ovale.

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