Migraine and PFO: Is there a link?

I've been going through the migraine/PFO drama for a couple of years now. In January of 2007, a TCD revealed a large hole in my heart, 4 on resting, 5+ on Valsalva. After my PFO closure procedure, the device failed and I was left with a hole perhaps, just slightly, a teensy bit smaller. A 3 on rest and a 5 on Valsalva.

A patent foramen ovale is a hole in the heart between the upper chambers. It's necessary before birth to allow circulation through the mother and fetus, as a fetus does not yet need his lungs to filter out the junk we all accumulate as our circulatory system works. After birth, upon first breaths, this hole should seal shut, allowing the blood to pass into appropriate chambers, freshly filtered from the lungs.

One in four adults, roughly 25% of the population, will have a heart that still has an open PFO. The PFO may or may not be large, and may or may not cause symptoms for its bearer over time.

The prevalence of PFO in migraineurs is slightly higher than in non-migraineurs. Many studies have shown that a larger PFO may be suspected in the role of migraine etimiology, particularly in sufferers who have pre-migraine pain warning symptoms such as aura.

There are many theories revolving around the PFO:

1. A PFO allows unfiltered and unoxygenated blood through to the brain, making the brain more susceptible to its migraine triggers;
2. A PFO is not a CAUSE of migraine, but may be implicted in perpetuating the migraine cycle in individuals whose migraines are not easily controllable by medications;
3. A PFO may cause a migraineur to be more susceptible to stroke (by allowing clots through to the brain). Divers with the bends, and other stroke patients, all with PFO, were among the first to discover that by closing the hole, their headache symtpoms disappeared.

These theories aren't met without hard questions however. During MIST I, a UK study generating the first-line results of the PFO/migraine debate, it was discovered that up to 37% of migraineurs with closure were migraine-free or suffering less frequently or intensely. Unfortunately the variables used during the study such as stroke victims, couldn't rule out the function of PFO and migraine exclusively. Its participants had already had focal neurological damage and would have been candidates for closure anyway. MIST II shut down shortly thereafter, claiming a cutoff of funding and perhaps controversy over examination findings and whether or not one of the lead investigators was truly qualified enough to BE an investigator. The MIST studies can be found through Heartwire, a cardiology journal. Beware, as most research articles go, you'll pay for the article if you want to see it. Here's a substitute article: MIST: Migraine Intervention with STARflex Technology Trials

The ESCAPE study, in which I have participated, was recently shut down for several reasons. On one hand, there has been positive anecdotal stories about successful closure. At my site, there were supposed to be around 500 study subjects; unfortunately about 50 is what we got. Out of those 50, 2 of us had incomplete closures (yours truly). The PREMERE device was pulled from study due to its ineffectiveness at closing ASDs and new study subjects were turned away. The device has been called too flimsy to work for PFO closure. There's an article for this failure, too: Just a 2% Overlap for PFO and migraine


There is always a double standard to research studies. Firstly, doctors want to know what works for any disease. And when you suffer from something that takes over your happy life, you know you're up for just about anything when it comes to getting a cure. That's where your research participation comes in. Secondly, there is always a medical institution that wants to make money by getting its device/medication out there for chronic use in treatments or surgeries, and by word of mouth for being the best option. My study device failed due to design failure and too little surface area to effectively shut my large PFO.

Recently, in Italy, a new study confirmed that yes, PFO closure works for migraine: Fixing a Hole in the Heart May be the Cure for Migraine Sufferers

However, why is it that Italy's study seems to have avoided controversy along with suggesting more than a casual link between PFO and migraine? It might have to do with the fact that they narrowed their criteria down to individuals with aura and large PFOs, rather than just anyone with a PFO of any size or any type of migraine.

So what does all of this mean, exactly? Well, we can't know for sure. What's known for sure is that many of us that experience migraine with aura have a PFO, but others do not. That makes it even more confusing. In my case, I experience migraine on a daily basis, with persistent aura. When I went in for closure, and the device was still seated correctly, I had no aura for months. However, I did still experience almost daily migraine attacks, but that was to be expected. Cessation of migraine attacks in individuals with PFO closure sometimes doesn't occur until the 4th month after closure, at the earliest. 6 months after PFO closure, my migraines got worse and my aura became permanent. 6 months after that, I discovered my PFO had been randomized into the test arm, but that the device failed.

What this means, for now, is that PFO closure is likely a future treatement for those with the most severe and debilitating attacks following aura. What we do know now, is that women who undergo migraine attacks with aura may be more susceptible to heart disease and stroke than those without aura: Migraine with Aura Linked to Cardiovascular Disease in Women

What I am hoping for is that this information will eventually come together in a way that most benefits the individuals who suffer with migraine. Personally, I think it's all linked, in one way or another, for many of us. For others, it likely won't be. But just the fact that these are new discoveries under investigation makes the future of migraine treatment look promising.