Case Presentation: A 44-year-old woman with a history of migraine headaches and generalized anxiety presented with sudden-onset, severe headache associated with left-eye lacrimation, blurry vision, and tingling and numbness of both upper extremities for one day. She described the headache as a throbbing pain mainly over the forehead. She denied nausea, vomiting, photophobia, or phonophobia. Given concern for a possible stroke, she underwent CT scan of the head and spine which showed no acute abnormalities. Neurology was consulted, and the patient was diagnosed with ocular migraine. She received a migraine cocktail consisting of valproate sodium 500 mg, Ketorolac 15 mg, and methylprednisolone 500 mg, with resolution of symptoms. As part of her workup, a transthoracic echocardiogram (TTE) was obtained revealing an ejection fraction of 60-65% and a positive bubble study consistent with intracardiac shunt. Due to the patient’s persistent interest in further evaluation, cardiology was consulted. Transesophageal echocardiography demonstrated a PFO with atrial septal aneurysm without evidence of thrombus in the left atrium or left atrial appendage. She underwent successful percutaneous catheter-based closure of the PFO using 25 mm Amplatzer device. Post procedure TTE showed a negative bubble study, with the septal occluder device in place and no residual shunt. At six-month follow up, the patient reported complete resolution of her migraines.
Discussion: Migraine and patent foramen ovale (PFO) are both common conditions. A potential association between the two has been debated for many years. The relation between migraines and PFO is a subject of interest because migraine affects more than 20% of the general population and they can have a significantly detrimental effect on quality of life. Some theories suggest right-to-left shunting of blood through the PFO, which allows substances normally filtered by the pulmonary circulation such as micro emboli and vasoactive chemicals to bypass the lungs and enter the cerebral circulation that can trigger cortical spreading depression, the electrophysiological event underlying migraine. However, the exact pathophysiological mechanism behind this remains unclear till date. (1)Several retrospective and observational studies have suggested that migraine symptoms may improve or even resolve following PFO closure, but evidence from randomized trials have been inconsistent. (2,3) The PRIMA trial, which focused on patients with unresponsive migraine with aura found that PFO closure did not significantly reduce monthly migraine days. The PREMIUM trial, a large double-blind RCT evaluating individuals with migraine and PFO showed a modest reduction in headache days and a higher rate of complete migraine remission in the closure group (8.5% vs. 1%). (4-6) Given these mixed results, current guidelines do not recommend routine PFO closure as a standard treatment for migraine. Initial consideration of closure in our patient was deferred for this very reason. However, due to her persistence in seeking definitive management, closure was pursued ,and she subsequently had complete remission of her migraines.
Conclusions: Our case underscores the possibility that PFO closure may offer meaningful relief in carefully selected patients with refractory migraine, even though current evidence does not support its routine use. Further robust clinical trials are necessary to clarify the mechanisms linking PFO and migraine and to identify which patients are most likely to benefit.