What is the last word on migraine and PFOs?

This is surely one of neurology’s bug bears, the old chestnut. Just when one generation of neurologists thinks it has buried and sealed it in an impervious crypt, it resurrects to haunt the next breed. This cyclical and macabre dance of migraine and PFOs evokes a sense of deja vu every time it comes around. And each spawn of neurologists predictably picks up the gauntlet, answers the call to arms, and sets out to slaughter the ghost of migraines past.

By Lille1982 – Own work, Public Domain, https://commons.wikimedia.org/w/index.php?curid=9682382

But let’s take a step back to basics with some definitions. The foramen ovale is just a ‘hole in the heart‘ between the right and left atria, or upper heart chambers. It is essential in foetal life because it enables circulating blood to bypass the superfluous foetal lungs (apologies to readers across the Atlantic for the superfluous ‘o’!). However, after birth, when blood needs to circulate through the now indispensable lungs, the foramen ovale becomes irrelevant. In most people, the foramen ovale humbly accepts its fate, crawls to a corner, and closes shop. But foramen ovales in some people are recalcitrant; standing their ground, they endure and survive as PFOs.

By DrJanaOfficial – Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=50477765

It is not clear how the myth started, but stories of migraine cure following surgical closure of PFO spread rapidly and widely. Very soon, migraineurs where demanding echocardiograms to check if they have PFOs lurking in their tickers. Research trials investigating this issue started as a trickle, and very soon become a flood. But rather than shed light, the conflicting results intensified the darkness. That is, until some indignant and determined neurologists and cardiologists set out to settle the matter once and for all. And the onslaught came in three waves of studies.

MIGRAINE. aka Tman on Flickr. https://www.flickr.com/photos/rundwolf/331545021

The first wave in the attempt to slay the beast of migraine and PFO was a trial published in the journal Headache. Davinia Larrosa and colleagues studied 183 people with migraine and found that, whilst PFOs were larger and more permanent in people with migraine, there was no relationship between patent foramen ovale and migraine frequency.

Migraine spectrum. JoanDragonfly on Flickr. https://www.flickr.com/photos/joandragonfly/26221136058

The second wave was a study published in the European Heart Journal by Heinrich Mattle and colleagues. In their PRIMA trial (Percutaneous Closure of PFO in Migraine with Aura), they blindly allocated or randomized half of their subjects with refractory migraine and PFO to have PFO closure surgery. And their verdict was, PFO closure did nothing to reduce the frequency of migraine.

Open the key to your heart. Maria Eklind on Flickr. https://www.flickr.com/photos/mariaeklind/24659701809

The third wave, launched by Nauman Tariq and colleagues, took a different tack. They carried out a detailed review of practically all the studies that had addressed the subject. Their brilliantly titled paper, “Patent foramen ovale and migraine: closing the debate, reflected their ambition to settle the question once and for all. After an arduous trawl through the literature, and a mind-blowing crunching of statistics, the authors came to the conclusions that “there is no good quality evidence to support a link between migraine and PFO“, and “closure of PFO for migraine prevention does not significantly reduce the intensity and severity of migraine“.

By Patrick J. Lynch, medical illustrator – Patrick J. Lynch, medical illustrator, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=1488277

The final word therefore is, leave PFOs alone! But there is a big caveat. There is one situation where PFO is associated with migraine, and that is when it is accompanied by another heart anomaly called an atrial septal aneurysm (ASA). The evidence for this comes from Roel Snijder and colleagues, and the title of their paper says it all: Patent foramen ovale with atrial septal aneurysm is strongly associated with migraine with aura: a large observational study. We already knew that PFO associated with ASA increases the risk of stroke; we can now add to this, the risk of migraine with aura.

By H. Airy – Flatau 1912 “Migrena” monograph after previous publication of H. Airy, Public Domain, https://commons.wikimedia.org/w/index.php?curid=7814450

The debate is now hopefully sealed and settled. But don’t hold your breath for too long: the phantom of migraine and PFO may just rear its hideous head again at a neuroscience centre near you.

 

The art of spinning catchy neurology headlines

The Neurology Lounge is always on the lookout for catchy neurology article titles to adorn its shelves. My previous blog post in this quest was The art of spinning catchy titles.

Since then, there have been quite a few brilliant article titles that have caught my fancy. We must acknowledge the wordsmiths who craftily and meticulously think up these magical headlines; they put in a lot of thought to conjure up the right words to use. The look into their crystal balls to predict the best way to play around with the meanings. With a bit of lexical alchemy, they miraculously come up with the titles that make us do a double-take, but do so with a smile. Below are 9 such catchy titles.

Parkinson’s disease: Oh my gut! 

By The original uploader was Arnavaz at French WikipediaThis image is an old version created by Medium69.Cette image est une ancienne version créée par Medium69.Please credit this : William Crochot – http://www.cancer.gov, Public Domain, Link

This title reflects the science suggesting that Parkinson’s disease originates from the gut. This editorial restates the proposition that α-synuclein starts accumulating in the intestines before migrating, up the vagus nerve, ‘in a prion-like fashion’, to the brain.

Patent foramen ovale and migraine: closing the debate

Medical Illustrations by Patrick Lynch, generated for multimedia teaching projects by the Yale University School of Medicine, Center for Advanced Instructional Media, 1987-2000.

Patent foramen ovale (PFO) is a hole in the heart which connects the upper two heart chambers, or atria. It normally closes after birth, but in some people it persists to cause some grief to cardiologists and neurologists. Whether a PFO causes migraine or not is a long standing contentious issue in Neurology. The authors of this study found no link between migraine and (PFO). The title is brilliant, but the tone of finality is probably premature; I guess this debate is far from over.

Migraine and inhibitory system – I can’t hold it!

Human brain on white background. _DJ_ on Flikr. https://www.flickr.com/photos/flamephoenix1991/8376271918

And still on migraine is this headline grabber. A bit on the basic science spectrum, I quote from the abstract to give you a flavour: ‘This review focuses on recent structural and functional neuroimaging studies that investigated the role of subcortical and cortical structures in modulating nociceptive input in migraine, which outlined the presence of an imbalance between inhibitory and excitatory modulation of pain processing in the disease‘. I would rather stick with the punchy headline myself.

On the nose: olfactory disturbances in patients with transient epileptic amnesia

Big Nose Strikes Again. Bazusa on Flikr. https://www.flickr.com/photos/bazusa/260401471

This research paper establishes a link between transient epileptic amnesia (TEA) and impairment of the sense of smell. TEA continues to surprise, and there is indeed quite a lot to chew in the paper.

Myelitis in neuromyelitis optica spectrum disorder: the long and the short of it

By JasonRobertYoungMDOwn work, CC BY-SA 4.0, Link

This is a clear play on the defining feature of neuromyelitis optica (NMO), a long segment of inflammation in the spinal cord. This is what neurologists call longitudinally extensive transverse myelitis (LETM). This is an excellent editorial, worthy of the headline. It emphasises the point that NMO really has no defining features, not even the presence of the ‘defining’ antibody, anti-aquaporin 4- just ask anti-MOG NMO about this

AEDs after ICH: preventing the prophylaxis

By BobjgalindoOwn work, GFDL, Link

How do you prevent a harmful preventative practice?. By a paper with a title that is pure genius of course. The authors of this paper highlight the persisting, anti-guideline, practice of using prophylactic antiepileptic drugs (AEDs) in people who have had intracerebral haemorrhage (ICH). The paper rhetorically asks if this has ‘become a habit too difficult to break?’ Not going by this catchy headline!

Paralysis lost: a new cause for a common parasomnia?

Sleepwalking. Gareth on Flikr. https://www.flickr.com/photos/trois-tetes/7240877

Parasomnias are diseases that occur during or related to sleep. This headline is for an editorial on a new parasomnia called anti IgLON5 antibody disorder. This is the subject of my previous blog post titled IgLON5: a new antibody disorder for neurologists. The headline writer here is clearly a fan of John Milton. I however struggled to make the connection between the excellent headline and the subject of the paper. I however presume it relates to the ‘loss of sleep paralysis‘ that accompanies many sleep disorders, including the quintessential parasomnia- REM sleep behaviour disorder (RBD). Excellent title anyway.

Hereditary spastic paraplegia: the pace quickens

By Rawlings, Leo – http://media.iwm.org.uk/iwm/mediaLib//150/media-150073/large.jpgThis is photograph Art.IWM ART LD 6040 from the collections of the Imperial War Museums., Public Domain, Link

With a slightly wicked wit, this headline focuses on the slow walking speed of people with hereditary spastic paraplegia (HSP), contrasting this with the increasing research output on the disease. A bit dated I admit, but the paper refers to work which identified the genetic basis of SPG3, one of the commoner HSPs. A lesson in headline writing from the archives you may say.

Cut your losses: spastin mediates branch-specific axon loss

Synapse. Ben Cadet on Flikr. https://www.flickr.com/photos/47814009@N00/2943548161

The headline is brilliant, but the content goes way over my head. It is an editorial on a basic science paper. For the curious and the nerdy, I quote an extract: ‘during synapse elimination in the developing neuromuscular junction, branch-specific microtubule destabilization results in arrested axonal transport and induces axon branch loss. This process is mediated in part by the neurodegeneration-associated, microtubule-severing protein spastin‘. Enough I hear you say. OK, just stick with the headline.

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Do you have any catchy titles-please drop a comment.

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