Doctor: Help for migraines is in the heart
Jennifer Kaut of Austin suffered with severe migraine headaches in her late teens, and as she got older, they got worse.
She would end up in the hospital once a week for pain shots. But for the past year, the 35-year-old mother of three says she has been migraine-free. The solution? A procedure to close a hole in her heart.
Closing the hole to treat migraines is rare and controversial, and there’s no scientific proof it works. But Dr. Manish Chauhan, a cardiologist at St. David’s North Austin Medical Center, said he thinks it cured Kaut and has helped others, despite conflicting scientific studies about its effectiveness.
Experts estimate that up to 25 percent of the population has an abnormal opening between the left and right sides of the heart’s upper chambers, called patent foramen ovale. That hole is needed by the developing fetus and generally closes soon after birth. When it doesn’t, most people live normal lives. But a hole in the heart increases the risk for stroke, and some studies say people who have migraines with aura – such as flashes of light, zigzagging patterns or tingling – are more likely to have a hole in their heart. But that, too, is controversial and has provoked dueling studies.
About 12 percent of Americans have migraines, with women three times as likely as men to be affected, according to the National Headache Foundation. Not everyone with migraines has a patent foramen ovale.
Studies to see whether closing them stops migraines have reached different conclusions.
Most recently, a small Italian study published earlier this year showed that all 40 patients who had the procedure reported that their migraines got better.
But a much-discussed 2006 study from the United Kingdom involving 147 patients, half of whom had a procedure in which a device was placed on the heart to close the hole, did not meet the goal of curing patients with migraines.
The study did show an estimated 37 percent reduction in frequency and length of migraines experienced by patients who had their patent foramen ovales closed and a 17 percent reduction in those who did not.
It also reported that some patients suffered severe side-effects, such as bleeding. In the end, researchers called for more study.
For now, Chauhan says he carefully selects patients and performs the procedure off-label, meaning the Food and Drug Administration has not given its approval but patients can receive treatment on a case-by-case basis. He also plans to take part in a national study involving 45 treatment centers that hope to enroll 230 patients followed over five years to help clear up the issue, which is sure to captivate some of the 29.5 million Americans who know the misery of migraines.
So how are the heart and head connected?
Theoretically, by chemicals in the blood.
Migraines are not well understood, but they are thought to have various triggers. One theory is that they are brought on by abnormal activation of the brain, which can result when there are chemical changes in the brain. A hole in the heart can allow chemicals or particles in the blood to pass through the left side of the heart and travel to the brain without being filtered by the lungs. Once there, those chemicals or particles can trigger a migraine.
In recent years, cardiologists began to notice that when they did procedures to close holes in the hearts of stroke patients, some who also had migraines reported improvement in their headaches. That was especially true when the migraine sufferer had an aura before or during the headache.
“This is not a definitive recommended therapy … but there is no doubt in my mind that there are patients that have dramatic results from this,” said Dr. Ralph Brindis, president of the American College of Cardiology and a cardiologist at Kaiser Permanente Oakland Medical Center in Oakland, Calif. “It’s an area ripe for research.”
Although cardiologists who do the procedure are divided about using it as a migraine treatment, neurologists – the doctors who treat migraines, most often with medication – seem even more skeptical.
Kaut’s neurologist, Dr. George Creel of Cedar Park, said he wants to see more rigorous studies before he renders an opinion on whether the procedure helps migraines. Kaut could have gotten better on her own, coincidental to the procedure, he said. And Dr. Ninan T. Mathew, director of the Houston Headache Clinic and past president of the American Headache Society and the International Headache Society, called the procedure a lot of “money-driven hype.”
Although someone who has a particularly large opening between the heart’s two chambers might get some relief from migraines with a closure, “it doesn’t cure the problem, and it’s only relevant for migraine with aura,” Mathew said.
He would recommend the procedure as a last resort for someone with a poor quality of life from migraines, he said.
Brindis said he would recommend it to patients who had not found relief from other treatments – as long as they understood there was no proof it would work and that there was a risk of complications such as bleeding, infection, stroke, damage to the heart and death. There isn’t accurate data on complication rates with procedures to close patent foramen ovales, he said.
Chauhan said he has done 12 to 14 of the procedures for migraine in the past year and has not seen complications in any of his patients.
“I’m a believer, but it’s not for everybody,” he said.
He doesn’t recommend it for patients unless they have “disabling migraines,” as Kaut did.
Patients who benefit the most are those who have neurological symptoms with their migraines, such as an aura, weakness in their arms, speech problems and other symptoms that resemble a minor stroke but go away when the migraine stops, Chauhan said.
Some insurance companies pay for the procedure as a migraine treatment, and some don’t, Chauhan said. The device he uses to close the hole, which is threaded through a tube inserted through the groin and guided to the heart, costs between $2,500 and $3,000, he said. He estimated the cost of the 30-minute procedure, including hospitalization, at “$30,000 or so.”
Kaut said her life had become one continuous headache. Occasionally, she would have a day without a migraine, but not often, she said. One night in January 2009, when she couldn’t sleep because of a migraine, she saw a segment on the Discovery channel about the procedure as a treatment for migraines. She found Chauhan, who tested her and found that she had a patent foramen ovale. She had the procedure in March 2009 and said the last migraine she had was when she entered the hospital to have the hole closed.
She gets mild headaches occasionally but can knock them out with over-the-counter medicine – something that never worked before, she said.
She owns a child behavior therapy business, which she started two years ago, and is convinced that she could not have kept it up if she had not had the procedure.
“It works,” Kaut said, “… and it’s not in my head.”
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By Mary Ann Roser
AMERICAN-STATESMAN STAFF