Migraine and patent foramen ovale: correlation, coexistence, dependence. A narrative review.

Abstract

Objective: This review was conducted to analyze the current knowledge on the topic of the relation between migraine and patent foramen ovale (PFO) and indicate the most crucial clinical implications.

Background: Migraine is a primary headache disorder that affects a significant part of the global population. Importantly, it has been considered a risk factor for ischemic stroke, especially in women with migraine with aura. The foramen ovale is a physiological opening in the atrial septum formed during fetal life, which closes in most people in the first year after birth. However, in some people, it can be present in adulthood and is called the patent foramen ovale. PFO is more likely to occur in patients with migraine compared to the population not experiencing migraine headaches.

Methods: Two review teams, comprising migraine experts and stroke experts, were engaged in the screening process, resulting in the inclusion of 204 relevant publications. To be considered for inclusion, an article had to directly cover the topic of PFO or migraine.

Results: In the following work, we have focused on several aspects regarding the direct and indirect relationship between migraine and PFO. Although analyzing migraine pathogenesis, apart from the straight link between PFO and migraine, others are also considered, such as a prominent Eustachian valve or Chiari valve, causing a high-risk PFO or a paradoxical embolism. Regarding the clinical practice, the prevalence of PFO and migraine, indications for exact therapies, and subsequently, neuroimaging in the view of PFO and migraine, have been scrutinized. Another crucial aspect of this review is the risk of stroke in patients with migraine, considering the PFO presence. It is suggested that patients with migraine have more vascular lesions on magnetic resonance imaging and more often experience strokes. Thus, the question arises whether PFO should be closed as stroke prophylaxis in every migraine patient.

Conclusions: Several aspects have been explored; however, more research is needed to draw clear conclusions with further indications for clinical practice. Nevertheless, it seems that not in all patients with migraine with PFO should the closure procedure be performed, but when the PFO is of a high-risk form or there are other indications, it should at least be considered.