Migraine–Patent Foramen Ovale Connection: Role of Prominent Eustachian Valve and Large Chiari Network in Migrainous Patients

Abstract

We postulated that eustachian valve (EV) and Chiari network (CN) play a role in the pathophysiology of both migraine and paradoxical embolism. We sought to prospectively investigate the potential role of EV/CN in migraine-patent foramen ovale (PFO) connection assessing their prevalence by intracardiac echocardiography (ICE) in patients with migraine submitted to PFO transcatheter closure. Over a 24-month period, we prospectively enrolled 50 consecutive patients (mean age 37+/-12.5 years, 38 females) with previous stroke and migraine referred to our centre for PFO catheter-based closure. Migraine with aura (MwA) and migraine without aura (MwoA) were diagnosed according to the International Headache Society criteria and Migraine Disability Assessment Score (MIDAS). Patients who met the inclusion criteria for closure underwent ICE study and closure attempt. After ICE study, a prominent EV or CN were diagnosed on ICE in 41 patients (82%): 100% in MwA patients, 60% in MwoA patients (p<0.001) and in 55.5% of patients with no migraine. Patients with EV and CN had more frequently a curtain pattern on TC Doppler, a larger right-to-left shunt, more recurrent cerebral paradoxical embolism before closure, and a higher preoperative MIDAS score. Patients with EV/CN had a larger decrease in MIDAS score after closure. This study suggests that EV and CN have a deep impact on MwA and paradoxical embolism pathophysiology: EV, CN, and MwA should be considered as adjunctive risk factors for paradoxical embolism in the work-up of both symptomatic and asymptomatic PFO patients.