antithrombotic treatment for migraine in patients with patent foramen ovale

Patent foramen ovale (PFO) is a remnant of the fetal circulation (1,2):

• foramen ovale is a channel between the left and right atria of the heart during the embryonic period
  • under normal physiological conditions, the foramen ovale will close in the first year after birth
    • if it is not closed after three years of age, it is termed as patent foramen ovale (PFO)
    • about 20-30% of adults have an incomplete fusion of the fossa, which is a permanent slit-like interatrial opening
    • usually, the blood pressure of the left atrium is higher than that of the right atrium, which will not cause right-to-left shunt
• multiple studies suggest that migraine is more prevalent in subjects with PFO and vice versa
  • PFO is associated with migraine, particularly migraine with aura, and been shown observationally to involve a possible microembolic mechanism
  • antiplatelet treatment (eg, aspirin or P2Y₁₂ inhibitors) has shown potential benefit in small studies

In a study to evaluate the efficacy and safety of antithrombotic treatment for migraine prevention in participants with PFO (2):

• for responder rate in patients with PFO and migraine, all three antithrombotic agents (aspirin, clopidogrel, and rivaroxaban) were non-inferior to metoprolol in reducing monthly migraine days or attacks by ≥50%
• rivaroxaban showed a higher responder rate than metoprolol
  • showed superior responder rates over metoprolol without an increase in major bleeding events
• findings suggest a potential microembolic mechanism contributes to migraine in patients with PFO

Reference:

1. Liu K, Wang BZ, Hao Y, Song S, Pan M. The Correlation Between Migraine and Patent Foramen Ovale. Front Neurol. 2020 Dec 1;11:543485.
2. Li Z et al. Antithrombotic treatment for migraine in patients with patent foramen ovale: multicentre, randomised, active controlled, open label trial.BMJ 2026; 394 :e100103.