What is the treatment approach for patients with migraines and a patent foramen ovale (PFO)?

From the Guidelines

The treatment approach for patients with migraines and a patent foramen ovale (PFO) typically begins with standard migraine therapies rather than immediate PFO closure. First-line treatment includes conventional migraine medications such as triptans (sumatriptan 50-100mg as needed), NSAIDs (ibuprofen 400-600mg), and anticonvulsants (topiramate 25-100mg daily) for prevention, as recommended by studies such as 1. Lifestyle modifications including regular sleep patterns, stress management, and trigger avoidance are also essential components. PFO closure is generally not recommended solely for migraine management unless the patient has experienced a cryptogenic stroke or has failed multiple medication trials with significant disability from migraines. The decision for PFO closure should be individualized and made after consultation with both neurology and cardiology specialists. Some key points to consider in the management of migraines include:

• Consider preventive treatment in patients who are adversely affected by migraine on ≥2 days per month despite optimized acute treatment, as suggested by 1.
• Use beta blockers, topiramate, or candesartan as first-line medications for prevention, as recommended by 1.
• Consider CGRP monoclonal antibodies as third-line medications for prevention, as suggested by 1.
• Lifestyle modifications and trigger avoidance are crucial in managing migraines, and patient education on these aspects is essential, as implied by 1. The rationale behind this approach is that while some studies suggest an association between PFO and migraines (particularly migraines with aura), clinical trials have shown inconsistent benefits of PFO closure for migraine reduction, and the proposed mechanism linking PFO to migraines remains theoretical and requires further research to establish definitive treatment guidelines.

From the Research

Treatment Approach for Patients with Migraines and a Patent Foramen Ovale (PFO)

• The treatment approach for patients with migraines and a PFO is a topic of ongoing research and debate 2.
• Observational studies suggest that closure of a PFO for other indications may reduce or even eliminate migraine attacks, particularly migraine with aura 2.
• However, randomized clinical trials such as the MIST, PRIMA, and PREMIUM trials have shown negative results for PFO closure as a preventive treatment for migraine 2.
• The PREMIUM trial did show a reduction in headache days in the migraine with aura subgroup, but the final results of this subset analysis have not been published 2.
• At this time, it is recommended against offering PFO closure as a preventive treatment for migraine, but patients for whom PFO closure is indicated for other reasons may see some improvement in their migraines 2.

Alternative Treatment Options for Migraine with Aura

• Topiramate and propranolol are two medications that have been studied for their effectiveness in treating migraine with aura 3.
• A comparative study found that topiramate and propranolol had similar efficacy in reducing migraine disability, but topiramate may be more effective in younger patients 3.
• Other treatment options for migraine with aura include triptans, ergotamine, and dihydroergotamine, as well as preventive treatments such as beta-blockers, calcium channel blockers, and antiepileptic drugs 4, 5.
• Anti-epileptic drugs such as topiramate and valproate are effective for migraine prophylaxis, but may have serious side effects and should be used with caution 6.

Important Considerations for Patients with Migraine and PFO

• Patients with migraine and PFO should be aware of the potential risks and benefits of PFO closure and discuss their treatment options with their healthcare provider 2.
• Women with migraine and PFO who are of childbearing potential should be aware of the potential risks of certain medications, such as valproate, and discuss alternative treatment options with their healthcare provider 6.
• Patients with migraine and PFO should also be aware of the importance of prompt treatment for migraine attacks, including the use of triptans and other medications, to reduce the risk of stroke and other complications 5.