The relationship between patent foramen ovale and migraine, dizziness and vestibular migraine, this article explains very clearly

In 2017, a case report published in the journal Headache of the American Headache Society reported a case of a 12-year-old female child with migraine with aura who had a headache during a diving class and was accompanied by neurological symptoms.
The child has patent foramen ovale (PFO)
.

The child has an obvious family history of migraine, a history of periodic vomiting between the ages of 3-6, and migraine with aura from the age of 7; migraine symptoms appear when she dives to about 15 feet, and the symptoms are floating in her.
After getting out of the water, he continued to aggravate, with narrow vision, a sense of disorientation, and then inflexible movement of his right hand
.

The final diagnosis was PFO under transthoracic echocardiography
.

It is generally believed that in the process of sinking and ascending, due to changes in hemodynamic force and valsalva action, the risk of temporary right-to-left shunt (RLS) is increased.
PFO is the most common cause of RLS.
At present, the positive result of RLS is regarded as equivalent to PFO in clinical practice
.

Author: Hu Tian Ye physician (Jiaxing First Hospital) This article is the author's permission NMT Medical publish, please do not reprint without authorization
.

Migraine, dizziness and vestibular migraine (vestibular migraine, VM) are common clinical neurological diseases, and there is a close relationship between these three
.

The foramen ovale is a physiological channel of the atrial septum of the heart during embryonic period.
Under normal circumstances, it will be closed in the first year after birth to form a permanent interatrial septum
.

But in about 20%-30% of adults, the foramen ovale is not closed after birth, so PFO is formed
.

This article will introduce the relationship between PFO and migraine, dizziness and VM from the current clinical research status
.

PFO and migraine PFO and migraine are in disagreement.
Most previous studies believe that PFO is closely related to migraine.
However, in recent years, more and more studies are opposed and believe that PFO and migraine should be viewed more rationally and objectively.
The relationship between headaches
.

The current research of support group generally believes that migraine with aura (MA) is closely related to PFO
.

Among all migraine patients, the prevalence of PFO in migraine patients with aura was 46.
3%-88%, and the prevalence of PFO in migraine patients without aura (migraine without aura, MO) was 34.
9%
.

Among them, the prevalence of PFO in migraine patients with atypical aura was 79.
2%, while the prevalence of PFO in migraine patients with typical aura was only 46.
3%
.

67% of non-migraine patients with visual aura suffer from PFO, and 80% of them have symptoms improved after PFO closure
.

In chronic migraine patients (chronic migraine, CM), whether with or without migraine aura, the prevalence of PFO is higher, and migraine patients with frequent visual aura are more likely to have severe RLS, which is closed in PFO Symptoms can be improved after surgery
.

Migraine patients with moderate to severe PFO have headache impact test-6 (HIT-6) and Migraine Disability Assessment questionnaire (MIDAS) scores than those with mild And non-PFO migraine patients are higher
.

RLS patients are relatively younger and have a higher proportion of sensory auras
.

In terms of PFO type, in patients with PFO, the incidence of permanent PFO is 67%-72%, and the incidence of latent PFO is 28%-33%
.

Permanent PFO is closely related to migraine and can trigger the onset of migraine
.

In terms of the size of PFO, nearly 75% of migraine patients have large shunts, and 25% of migraine patients have small shunts.
Among all PFO patients, large PFOs (≥4.
0mm) are in the migraine compared with healthy individuals.
It is more common in patients with headache; permanent PFO and large PFO are more common in patients with migraine, especially MA
.

Although the number of minor shunts is similar in migraine patients and healthy individuals, the frequency of mild to moderate shunts is higher in migraine patients
.

PFO patients first developed MA at a younger age, and the severity of PFO is also related to the occurrence of MA at a younger age
.

This feature is also present in PFO patients with atrial septal aneurysm (ASA)
.

The family history of MA is related to the occurrence of PFO, and the age of onset is not affected by thrombosis or other vascular factors
.

A study evaluating the long-term efficacy of transcatheter PFO closure surgery for migraine patients verified the relationship between PFO and migraine from a therapeutic point of view
.

The study found that PFO closure can significantly reduce the burden on migraine patients, regardless of whether they are accompanied by aura
.

Migraine is closely related to PFO with ASA, and this connection may increase the shunt flow and lead to the occurrence of migraine
.

An opposition study on CM and paroxysmal migraine (EM) believes that PFO is not more common in CM than in EM, and that PFO has nothing to do with the frequency of migraine attacks
.

The study found that in EM or CM, the prevalence and degree of PFO are not related to the presence or absence of aura
.

In another study on the effectiveness of PFO closure in migraine patients using the Amolatzer PFO occluder, it was concluded that PFO closure did not achieve the main findings of reducing attacks
.

PFO and vertigo A clinical study on the effectiveness of RLS shunting in the treatment of benign paroxysmal positional vertigo (BPPV) in adolescents found that RLS is an independent risk factor for BPPV in adolescents, and the results of this study can be RLS Provide hypotheses about the pathogenesis of BPPV in adolescents
.

The study also found that RLS microemboli is a risk factor for stroke in young people and is more likely to affect the posterior circulatory system
.

In adolescents without obvious traditional risk factors for cerebrovascular disease, RLS may be one of the factors that cause inner ear ischemia
.

There is a case report of a middle-aged man with sudden neurological deafness and vertigo.
He was finally diagnosed with small PFO (0.
5mm).
After receiving antiplatelet therapy, his symptoms resolved.
There was no recurrence after 18 months of follow-up
.

This is a case of small PFO with ASA.
A series of examinations were performed during the diagnosis process, including routine ENT examinations, pure tone hearing examinations, and neurological examinations.
Only the right level of spontaneous nystagmus was found
.

Finally, a transthoracic echocardiography was performed and ASA was found, and RLS was found in a subsequent transesophageal echocardiography
.

The possible pathogenesis of neurological deafness in this case can be explained by the paradoxical embolization of PFO
.

PFO and VM A study on the incidence of RLS in familial clusters and sporadic VM patients and the correlation between their severity and symptoms confirmed that there was no significant correlation between the familial clusters of VM and RLS; headache and visual aura symptoms in VM patients The relationship with RLS is closer, and the more severe the RLS caused by PFO, the more likely it is to have headaches and visual aura symptoms
.

A clinical study on the treatment of VM with PFO occlusion surgery believes that PFO occlusion surgery has a good effect on VM.
After the operation, patients have clinical symptoms, migraine score, visual analogue scale (VAS), and Hamilton anxiety scale ( Hamilton anxiety scale (HAMA) scores and Hamilton depression scale (Hamilton depression scale, HAMD) scores all improved
.

Judging from the current research, whether it is the relationship between PFO and migraine or with vertigo or VM, most studies are still focused on clinical research.
Among them, the relationship between PFO and vertigo and VM still requires a large number of high-quality and large-sample studies.
Provide evidence
.

The relationship between PFO and the three can be summarized as the following figure (Figure 1, Figure 2 and Figure 3)
.

Figure 1 The relationship between PFO and migraine Figure 2 The relationship between PFO and vertigo Figure 3 Summary of the relationship between PFO and VM The pathogenesis is still unclear, especially the relationship between PFO and vertigo and VM
.

However, this does not prevent us from clinically paying attention to the potential relationship between PFO and vertigo and VM.
In the diagnosis of unexplained vertigo and VM, the possibility of PFO should be considered
.

For some special professional personnel, such as divers, necessary inspections should be made to rule out the possibility of PFO as soon as possible
.

References: 1.
Ashhar A, David R, Migraine With Neurological Features in a Scuba Diver With a Patent Foramen Ovale.
Headache.
2017, 57(4):658-662.
2.
Liu KM, Wang BZ, Hao YS, et al.
The Correlation Between Migraine and Patent Foramen Ovale.
Front Neurol.
11:543485.
3.
Chinese expert consensus on preventive occlusion of patent foramen ovale[J].
Chinese Journal of Circulation,2017,32(3):209-214.
4.
Tobis JM , Charles A, Silberstein SD, et al.
Percutaneous Closure of Patent Foramen Ovale in Patients With Migraine The PREMIUM Trial.
J Am Cardiol.
2017; 70(22):2766-2774.
5.
Ciorba A, Corazzi V, Cerritelli L, et al .
Patent Foramen Ovale as Possible Cause of Sudden Sensorineural Hearing Loss: A Case Report.
Med Princ Pract.
2017; 26(5):491-494.
6.
He YT, Deng J, Cai ZL, et al.
Effect of right-to- left shunt on youth benign paroxysmal positional vertigo: A prospective clinical study.
Clin Neurosurg.
2021, 205: 106646.
7.
Assa EB, Moreno PR,Bawardy RA, et al.
Effect of Residual Interatrial Shunt on Migraine Burden After Transcatheter Closure of Patent Foramen Ovale.
JACC Cardiovasc Interv.
2020, 13(3): 293-302.
8.
Larrosa D, Ramon C, Alvarez R, et al.
No Relationship Between Patent Foramen Ovale and Migraine Frequency.
Headache.
2016, 56(9): 1466-1473.
9.
Altamura C, Paolucci M, Brunelli N, et al.
Patent foramen ovale and migraine with aura in a retrospective analysis: age matters.
Neurol Sci.
2018, 39(Suppl 1): 103-104.
10.
Wei Jing, Zhao Libo, Li Chao, et al.
Observation on the efficacy of interventional closure of patent foramen ovale in the treatment of vestibular migraine[J].
Beijing Medicine, 2021 , 43(6):512-516.
11.
Zhang Lina, Jilin Zhu, Hou Chen, et al.
The relationship between right-to-left cardiac shunt and familial clustered vestibular migraine[J].
Journal of Clinical Internal Medicine, 2021,38( 5):305-307.
No Relationship Between Patent Foramen Ovale and Migraine Frequency.
Headache.
2016, 56(9): 1466-1473.
9.
Altamura C, Paolucci M, Brunelli N, et al.
Patent foramen ovale and migraine with aura in a retrospective analysis: age matters.
Neurol Sci.
2018, 39(Suppl 1): 103-104.
10.
Wei Jing, Zhao Libo, Li Chao, et al.
Observation on the efficacy of interventional closure of patent foramen ovale in the treatment of vestibular migraine[J].
Beijing Medicine, 2021, 43(6):512-516.
11.
Zhang Lina, Jilin Zhu, Hou Chen, et al.
The relationship between right-to-left cardiac shunt and familial clustered vestibular migraine[J].
Journal of Clinical Internal Medicine, 2021,38 (5):305-307.
No Relationship Between Patent Foramen Ovale and Migraine Frequency.
Headache.
2016, 56(9): 1466-1473.
9.
Altamura C, Paolucci M, Brunelli N, et al.
Patent foramen ovale and migraine with aura in a retrospective analysis: age matters.
Neurol Sci.
2018, 39(Suppl 1): 103-104.
10.
Wei Jing, Zhao Libo, Li Chao, et al.
Observation on the efficacy of interventional closure of patent foramen ovale in the treatment of vestibular migraine[J].
Beijing Medicine, 2021, 43(6):512-516.
11.
Zhang Lina, Jilin Zhu, Hou Chen, et al.
The relationship between right-to-left cardiac shunt and familial clustered vestibular migraine[J].
Journal of Clinical Internal Medicine, 2021,38 (5):305-307.