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Patent foramen ovale, migraine and stroke: no reason to intervene

Nature Clinical Practice Cardiovascular Medicine volume 3, pages 176–177 (2006)Cite this article

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Cardiac embolism is the most frequent cause of ischemic stroke in hospital-based and population-based registers. Patent foramen ovale (PFO) with and without atrial septal aneurysm (ASA) has been recognized as a potential risk factor for ischemic stroke. Besides paradoxical embolism from small thrombi that arise in the venous system and cardiac thrombus formation secondary to PFO-related or ASA-related cardiac arrhythmia, another likely ischemic stroke cause is thrombus formation in the PFO.

Transesophageal echocardiography studies have confirmed increased prevalences of PFO and ASA in young patients with unexplained causes of stroke—cryptogenic stroke.1 In a meta-analysis of case–control studies, Overell et al. concluded that a patient's relative risk (RR) of stroke increased by 1.83 (95% CI 1.25–2.66) if a PFO was present compared with nonstroke controls without PFO.2 In patients younger than 55 years, the same meta-analysis found that the RR for stroke increased by 3.10 (95% CI 2.39–4.21) in patients with PFOs. Case–control studies, however, provide only modest evidence and several studies did not have standardized examination protocols or properly masked investigators. Sufficiently large longitudinal studies in asymptomatic patients with PFO are not yet available and would require 100,000 person-years to detect an RR of 1.5 with a power of 80%. Overell and coworkers show that PFO probably is a risk factor for stroke, especially in young people. The RR of stroke in older PFO patients is hardly detectable because of multiple other vascular risk factors. The high prevalence of PFO in the general population (25–30%), the questionable association of stroke and PFO, and the low stroke rate in younger people, together result in an unreasonable cost : benefit ratio for PFO screening.

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Acknowledgements

Supported by the German Ministry of Research and Education within the German Headache Research Network (01EM0117).

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  1. Professor and Chairman and C Weimar is Consultant Neurologist at the Department of Neurology, University Duisburg-Essen, Germany

    Hans-Christoph Diener & Christian Weimar

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  1. Hans-Christoph Diener
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  2. Christian Weimar
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Correspondence to Hans-Christoph Diener.

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The authors declare no competing financial interests.

Supplementary information

Supplementary Reference List 1

Retrospective studies demonstrating migraine improvement following PFO closure.

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Diener, HC., Weimar, C. Patent foramen ovale, migraine and stroke: no reason to intervene. Nat Rev Cardiol 3, 176–177 (2006). https://doi.org/10.1038/ncpcardio0519

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