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Migraines and Patent Foramen Ovale

It has been known for some time that there is an association between a birth defect called patent foramen ovale (PFO) and migraines, particularly migraines with aura.� The subject came up again on the front page of my local newspaper, the Houston Chronicle, as the lead article with huge headlines.

Here are the facts: the PFO is a congenital condition where a hole exists in the wall between two chambers of the heart that allows blood to pass through while you are a fetus.� Since fetuses don’t breathe through lungs, but instead receive oxygenated blood from the mother through the placenta, the PFO allows mom’s blood to pass through directly into the baby’s circulation and bypass the lungs.

What happens is that after birth, the PFO closes up rapidly, once the lungs start working.� In about 25% of the population the PFO is still present as a flap that covers the hole but only opens when there is a high pressure situation inside the chest - like sneezing or bearing down while having a bowel movement.

Most people with PFO live their entire life without ever knowing they had it because it usually causes no problems.� However, some cases of strokes can occur with PFO and researches have found an association with migraine headaches with aura.

About seven studies have been done on people who have strokes and migraines with PFO.� After surgically closing the defect, about half the people with migraines reported significant reductions or elimination of them after the procedure.

There is one study still in process, called MIST - Migraine Intervention with StarFlex Technology (named after the implanted surgical device that covers the hole).� This is the only to date enrolling patients without a stroke.� All of the others had stroke patients that required heart surgery.

The results are not available yet, but it somehow made the front page of the Houston newspaper today mainly to recruit patients to a Houston heart surgery center.� There were three interviews of women with migraines in the article.� One had a reduction of migraines from 3 -4 a week down to two migraines in the last couple of months.� The other two women interviewed had no improvement.

If they were trying to recruit patients for their study with these kind of results, they will have a difficult time with these results.

What are my thoughts?� First, migraine with aura is uncommon.� Only 10% of migraneurs have migraine with aura.� (My observation is that the percentange of migraines with aura is vastly overstated). But in one study, they estimated that about a fourth of people that have migraines with aura also have a PFO.

Perhaps the PFO allows the passage of chemicals, substances, particles or hormones into the brain that normally would have been trapped in the lungs?� The mechanism is unknown.

In any event, not a single researcher recommends that people with migraines who have a PFO undergo�a heart surgery (even though it is a relatively simple procedure) just to attempt to eliminate the migraines.� Even they recommend that all medication measures must be exhausted first.

However, those people who also have a had a stroke are highly recommended to have the procedure.� I agree.� Strokes are far more dangerous and must be taken seriously.� If strokes can be prevented by this procedure then do it - and if the migraines with aura go away, then that is a nice bonus.

However, for most people with migraines, especially women,�it remains largely a hormonal issue and treated accordingly.� The appropriate treatment for migraines of all types is to start with bio-identical hormone replacement.� An 80% curative response is our typical outcome.

Andrew Jones, M.D.

Medical Director, Women’s Health Institute of Texas





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