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Anatomy of a Migraine: Doctors Explore Whether Closing a Gap in the Heart Can Curb Severe Headaches

Posted on: Saturday, 8 April 2006, 06:00 CDT

By Jean P. Fisher, The News & Observer, Raleigh, N.C.

Doctors at Duke University Hospital are testing a bold new approach to treat migraines: fixing a flaw in the heart to bring relief to the head.

About half of migraine sufferers have small openings in their hearts that develop as a normal part of the fetal circulatory system but that usually close at birth. The opening is linked to a higher risk of stroke.

But when doctors closed the gap as a means of stroke prevention, many patients who also had migraines reported that headaches were less severe and less frequent.

Now patients and their doctors hope the accidental finding will lead to a breakthrough in migraine treatment. Duke is one of 10 medical centers nationally participating in a clinical trial that will determine whether closing the opening in patients' hearts is effective at easing migraines.

An estimated 28 million Americans, about 13 percent of the population, suffer from migraines, according to the National Headache Foundation. Up to a quarter of women have the headaches.

Doctors prescribe medicine to prevent migraines, but up to a third of patients don't respond to treatment, said Dr. Kerstin Bettermann, a neurologist at Wake Forest University Baptist Medical Center in Winston-Salem. Other medicines to shorten the duration of migraines are expensive and can have unpleasant side effects.

Many migraine patients probably won't be put off at the prospect of a heart catheterization procedure if it can ease their suffering. Migraine headaches are often debilitating, lasting hours or even days, and can make it difficult to work or spend time with friends and family.

On Friday, Deborah Kerr, who has had severe migraines for more than 30 years, became the first patient to have the procedure as part of the Duke trial. Kerr, 53, who lives in Bristol, Va., has tried everything. She has taken morphine, anti-seizure pills and antidepressants, commonly prescribed for migraines, with little relief. A couple of times she was hospitalized and given anesthesia to knock her out as a respite.

Thank heaven for photographs. Without them, Kerr said, migraines might have stolen most of her memories of raising two sons.

"I was just so medicated," she said. "I don't actually remember rocking [my oldest son], or anything like that. I remember from pictures."

She hopes undergoing the procedure to close the gap in her heart will mean she has to rely less on Zomig, which she takes to shorten migraines. It costs about $100 for six pills.

Heart history

In most people, the heart's two sides have no openings between them. Circulated blood flows into the right side of the heart. It then goes to the lungs, where it is filtered and replenished with oxygen. From the lungs it goes to the left side of the heart, which sends it on to the brain and body.

When a fetus is in the womb, however, it relies on its mother for blood and doesn't use its lungs. As a result, the fetal heart has an opening known as the patent foramen ovale or PFO. The opening allows blood to take a short cut from the upper right side of the heart to the upper left side, which then sends it on its usual path.

Typically, when lungs kick into action at birth, pressure in the heart increases, the PFO slams shut and the tissues grow together, forming a permanent seal.

But in up to 30 percent of people, the flaps of tissue press together but never fuse. This can allow unfiltered blood to escape into the left side of the heart. Doctors speculate that chemicals or tiny blood clots in the unfiltered blood may cause migraines.

A team of Duke doctors led by cardiologist John Rhodes will do procedures to close patients' PFOs for the trial.

The team feeds long, thin probes into blood vessels in the patient's thighs to gain access to the heart. A small metal disc with tiny anchors on it is maneuvered onto a flap of tissue. Then doctors draw an opposing flap of tissue toward the disc. The anchors hold the flaps together and, over time, tissue grows over the device, sealing the opening.

Kerr, who discovered the trial online and asked to be enrolled, knew in advance she would have the procedure.

But others will not know whether they are part of the group that has the PFO closed or part of a control group that will undergo fake catheterizations. All patients will wear goggles that obscure their vision and listen to music on headphones to distract them. The trial will enroll 500 patients.

Doctors will anesthetize and make incisions in the thighs of patients who do not get the closure, so they will not know whether they had the procedure. The ruse is necessary to prevent skewed results from patients who might imagine better or worse results depending on which study group they are in. Both groups of patients will receive medicine to shorten the duration and intensity of headaches.

No one expects closing the PFO to end migraines completely. A British study recently reported that people experienced at least a 50 percent decline in the number of days they had the headaches after the procedure. Kerr, who has at least two migraines a week, would be thrilled with any reduction.

"If I could have them just once or twice a month, that would be wonderful," she said.

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