Related Experiment Video
Updated: Feb 12, 2026
Closure of a Patent Foramen Ovale PFO: An Intervention Sequence
Published on: December 23, 2022
Frequency of Patent Foramen Ovale and Migraine in Patients With Cryptogenic Stroke
Brian H West1, Nabil Noureddin2, Yakov Mamzhi1
1From the Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA (B.H.W., Y.M., A.C.C., E.J.S., R.G.F., J.M.T.).
Background And Purpose:
Individuals with migraine are at higher risk for stroke, but the mechanism has not been established. On the basis of the association between migraine and intracardiac right-to-left shunt, it has been proposed that stroke in migraineurs could be caused by a paradoxical embolus passing through a patent foramen ovale (PFO) or pulmonary arteriovenous malformation. The aim of this study was to determine the prevalence of PFO with right-to-left shunt in patients who presented with cryptogenic stroke and had a history of migraine.
Methods:
Patients between 18 and 60 years old who presented with an ischemic stroke were characterized based on ASCOD phenotyping (atherosclerosis; small-vessel disease; cardiac pathology; other causes; dissection). A migraine diagnosis was identified by reviewing physician notes, and frequent aura was defined if present in at least 50% of attacks. A PFO with right-to-left shunt diagnosis was identified by the presence of a positive bubble contrast study with either transcranial Doppler, transthoracic, or transesophageal echocardiography.
Results:
Of the 712 patients who presented with ischemic stroke, 127 (18%) were diagnosed as cryptogenic; 68 patients had adequate testing for PFO and a documented migraine history. The prevalence of PFO in patients with cryptogenic stroke without migraine was elevated (59%) compared with the general population (18%). Patients with both cryptogenic stroke and migraine had a higher prevalence of PFO (79%). In patients with cryptogenic stroke who had migraine with frequent aura, the prevalence of PFO was 93%. Only 5 patients (4%) had a history compatible with migrainous infarction.
Conclusions:
In patients with cryptogenic stroke who have migraine, there is a high prevalence (79%) of PFO with right-to-left shunt. The timing of the stroke in migraineurs is usually not related to a migraine attack. These observations are consistent with the hypothesis that the mechanism of stroke in migraineurs is most likely because of a paradoxical embolus. Future cryptogenic stroke classification schemes should consider including PFO as a separate etiologic category.
Insights
Migraine patients with cryptogenic stroke have a high prevalence of patent foramen ovale (PFO) with right-to-left shunt. This suggests paradoxical emboli through PFO may cause stroke in migraineurs, independent of migraine attacks.
Area of Science:
- Neurology
- Cardiology
- Vascular Medicine
Background:
- Migraine is linked to increased stroke risk, but the underlying mechanism remains unclear.
- A proposed mechanism involves paradoxical emboli from intracardiac shunts, such as patent foramen ovale (PFO).
- This study investigates the prevalence of PFO in stroke patients with a history of migraine.
Purpose of the Study:
- To determine the prevalence of PFO with right-to-left shunt in patients presenting with cryptogenic stroke and a history of migraine.
- To explore the association between migraine characteristics and PFO prevalence in this patient group.
Main Methods:
- Ischemic stroke patients aged 18-60 were assessed using ASCOD phenotyping.
- Migraine diagnosis and frequent aura (≥50% of attacks) were identified from physician notes.
- PFO with right-to-left shunt was diagnosed via positive bubble contrast studies (Doppler, echocardiography).
Main Results:
- Of 712 stroke patients, 127 (18%) had cryptogenic stroke; 68 had PFO testing and migraine history.
- PFO prevalence was 59% in cryptogenic stroke patients without migraine (vs. 18% general population).
- PFO prevalence was significantly higher in patients with both cryptogenic stroke and migraine (79%), reaching 93% in those with frequent aura.
Conclusions:
- A high prevalence (79%) of PFO with right-to-left shunt exists in cryptogenic stroke patients with migraine.
- Stroke timing in migraineurs is typically unrelated to migraine attacks, supporting the paradoxical embolus hypothesis.
- PFO should be considered a distinct etiologic category in future cryptogenic stroke classifications.
Related Concept Videos
01:21Frequency-dependent Selection
00:51What is a Frequency Distribution
01:11Mean From a Frequency Distribution
When such a data set is encountered,...
01:27Regulation of Stroke Volume
Preload refers to the degree of stretch on the heart before it contracts. It's analogous to the stretching of a rubber band; the more it's stretched, the more forcefully it snaps back. This concept is encapsulated in the Frank-Starling law of the...
01:22Muscle Stimulation Frequency
Wave summation
At low firing rates, motor neurons induce individual twitch contractions in muscle fibers. These twitches...
01:24Frequency Response of BJT
Low-Frequency Response: At low frequencies, the behavior of the BJT is determined by its DC bias point, which is set by the...