Migraine with aura and patent foramen ovale: myth or reality?

C. Finocchi, M. Del Sette

Several observational studies report that subjects with migraine with aura have a higher prevalence of right-to left shunt, commonly due to patent foramen ovale, and that patent foramen ovale is more prevalent in subjects with migraine with aura. Although migraine without aura has been less extensively studied, it does not seem to be associated with an increased prevalence of right-to left shunt. The mechanism that underlies the possible relationship between patent foramen ovale and migraine with aura remains speculative. The proposed mechanisms are migraine-triggering vasoactive chemicals bypassing the pulmonary filter and reaching the cerebral circulation and paradoxical microembolization. However, it is unclear, at this time, if there is a causal or comorbid association between the two conditions. In some families atrial shunts show a dominant inheritance that seems to be linked to inheritance of migraine with aura. Migraine with aura is an independent risk factor for ischemic stroke, and patent foramen ovale is present more frequently in patients with cryptogenic stroke than in controls. At this moment, there is no convincing evidence that excess stroke risk of migraine is simply mediated by patent foramen ovale through paradoxical embolism. Several non-controlled studies suggest that closure of the foramen ovale significantly reduces attack frequency in migraine patient, but the only prospective placebo-controlled trial does not support these results. Patent foramen ovale closure, at present, is not indicated as a treatment for migraine in clinical practice.