FAQ Episode 64: Dizziness with your migraine, is there a heart connection?
Frequently Asked Questions about Natural Migraine Relief
A December 2024 article in Frontiers in Neurology1 looked at a problem we’ve known about for some time. Let’s start with the backstory. Before each of us were born, we had a connection between the two upper chambers of our heart, allowing maternal blood to bypass the lungs. After birth when the lungs begin ventilating this connection, known as the foramen ovale, should close completely as is does in some 75% of us. Sometimes this can remain as a residual opening, called a patent foramen ovale (PFO), which persists into adult life for ~one out of four people. It is the most common congenital cardiac anomaly in adults.
A PFO can cause additional oxidative stress on our platelets. This can:
cause additional wear and tear on the cells
initiate platelet aggregation (clumping)
allow resulting micro-clots to develop and become a factor in brain vascular problems like migraines or strokes.
This vascular effect can exaggerate migraines of all varieties. The Frontiers in Neurology study looked specifically at vestibular migraines, where symptoms with or preceding a migraine can include:
Vertigo: a feeling of spinning or moving that can last from seconds to days
Dizziness: a feeling of unsteadiness or loss of balance
Hearing symptoms: ringing, fullness, or pressure in one or both ears
Visual symptoms: sensitivity to light, bright lights, or strong smells
Nausea: vomiting may also occur.
In this study researchers looked at the potential benefit for these concerns by minimizing the right to left blood shunting effect of two similar malformations:
a patent foramen ovale (PFO)
a similar shunt that can occur in the lungs, known as a pulmonary
arteriovenous malformation (PAM)
What they found
First off, they were looking at the benefits of closing a medium to large shunt (> 2 mm.) Typically this is identified with an echogram of the heart, or during a catherization procedure. The study did not identify how the shunt problem was found in these individuals. We could postulate that an audible heart murmur was found on a routine exam and then followed up. Or perhaps they had a echo study or heart catheterization done for another reason that inadvertently identified the shunt condition. In any case, the repair of the shunt condition (either PFO or a PAM) resulted in significant improvement in all parameters of either migriane or associated vestibular symptoms. It should be noted that only 22% of those treated had a complete resolution of all migraine and vestibular symptoms. This should remind us that migraines typically have multiple root contributing factors that benefit from identification and management.
Why did the shunt repair reduce migraines?
When a PFO is closed, it can clean up several factors predisposing to migraines:
after a shunt repair, the underoxygenated blood from the right heart is no longer mixed with the blood leaving the left heart to go to the brain. This means the brain will get more oxygen, make more ATP energy, and have more stable nerve conduction stability and a better threshold for resisting a migraine.
there is a degree of wear and tear on red cells traversing the shunt, which results in:
-a breakdown of red cells and a potential for anemia, i.e. one more version
of reduced oxygen delivery.
-inflammatory changes on red cells and platelets, making them “more
sticky.” This can result in microemboli and endothelial (inner blood
vessel layer) inflammation, which can be migraine triggering factors.
This can be especially important for those with an associated aura
with their migraine.
How would you know that you had a right to left shunt problem, or that it was a factor in your migraines?
People in the study described above were selected because they had a shunt problem indentified and also had migraine headaches (specifically with vestibular symptoms.) Most migraineurs have no idea if they have a right to left shunt problem (although ~25% of people have some degree of a PFO.)
Note the PFO opening between the left and right atria in this cardiac ultrasound
You might be a candidate to have this evaluated with a diagnostic cardiac echo with Doppler, or a trans-esophogeol echo with microbubble infusion if:
a health professional has identified a murmur in your heart, even if it has been termed an “innocent murmur.” A PFO murmur is often described medically as a “soft midsystolic murmur at the upper left sternal border with wide and fixed splitting of the 2nd heart sound (S2).”
you also have a meaningful aura with your migraine, especially if vestibular components are present.
you’ve had any stroke or seizure like symptoms associated with your migraines. In one study2 33% of patients presenting with their first ischemic stroke had an underlying PFO.
if a sclerotherapy treatment session for varicose veins seemed to provoke a migraine with an aura. In this situaton, small amounts of the sclerosing agent could find their way across the PFO and end up inflamming cerebral arterial vessels.
any combination of the above factors, especially if your migraines are intractable and resistant to other forms of therapy.
Most patients with migraine will not have a clinically significant heart shunt problem. But if you are one of them, you may benefit from an individualized consideration of diagnostic and treatment options. Its useful to remember that while a factor predisposing or complicating a migraine may not be common, if it applies to you, it could be 100% true for you.
If you would like to know more about this topic, paid subscribers can review the Natural Migraine Relief Course’s Lesson 22: PFOs as a Root Cause factor in Migraine with aura.
“Short-term efficacy of right-to-left shunt closure in patients with vestibular migraine.” Front. Neurol., 11 December 2024 Yilin Lang, et. al. https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2024.1500918/abstract
“Patent foramen ovale size and embolic brain imaging findings among patients with ischemic stroke” M M Steiner et. al. Stroke. 1998 May;29(5):944-8. doi: 10.1161/01.str.29.5.944. https://pubmed.ncbi.nlm.nih.gov/9596240/