Is ultrasound foam

sclerotherapy

contraindicated

in patients with migraine?By Claudine HAMEL-DESNOS, Caen, France

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FoamPatent

foramen ovale

MIGRAINE

Neurological

disturbances?

Should we treat varicose veins using UGFS* in patients with migraine?

*Abbreviations: PFO, patent foramen ovale;

UGFS,

ultrasound-guided foam sclerotherapy

Meier B et al. Eur Heart J 2012;33:705-713

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« The results of NOMAS can be seen as the strongest evidence against an association between

migraine or migraine with aura and PFO »

Kurth K, Tzourio C, and Bousser MG. Editorial

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How does foam progress?• In vitro,

2 ml of 3% sodium tetradecyl sulphate are deactivated by only 1 ml of blood in a short period of time (15 s)

• The sclerosing agent does not reach the brain circulation

• Only “bubbles” remain

Watkins M.R. Deactivation of sodium tetradecyl sulphate injection by blood proteins. Eur J Vasc Endovasc Surg. 2011;41:521-525. 4

Neurological disturbances

• Visual (1.4%)

• Migraine (4.2%)

• Transient ischemic attacks

• Stroke

Jia X, Mowatt G, Burr JM, Cassar K, Cook J, Fraser C. Systematic review of foam sclerotherapy for varicose veins. Br J Surg. 2007;94(8):925-936.

Mostly case reports Good recovery

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What’s a migraine?

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The International Headache Societymigraine without aura: diagnostic

criteriaA. At least 5 attacks fulfilling criteria B-D

B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)

C. At least two of the following characteristics:

– Unilateral location

– Pulsating quality

– Moderate or severe pain intensity

– Aggravation by or causing avoidance of routine physical activity (eg walking or climbing stairs)

D. At least one of the following symptoms:

– Nausea and/or vomiting

– Photophobia and phonophobia

E. Not attributed to another disorder

The International Classification of Headache Disorders. Cephalalgia. 2004;24:S9-S160. 7

A. At least 2 attacks fulfilling criteria B-D

B. Aura consisting of at least 1 of the following, but no motor weakness: 1. fully reversible visual symptoms including positive features (eg, flickering

lights, spots, or lines) and/or negative features (i.e, loss of vision);

2. fully reversible sensory symptoms including positive features (i.e, pins and needles) and/or negative features (i.e, numbness);

3. fully reversible dysphasic speech disturbance

C. At least 2 of the following :

1. homonymous visual symptoms and/or unilateral sensory symptoms

2. at least 1 aura symptom develops gradually over ≥5 min and/or diferent aura symptoms occur in succession over ≥5 min

3. each symptom lasts >5 and <60 minutes

D. Headache fulfilling criteria B-D for migraine without aura begins during the aura or follows the aura within 60 minutes

E. Not attributed to another disorder

The International Headache Societymigraine with aura : diagnostic

criteria

The International Classification of Headache Disorders. Cephalalgia. 2004;24:S9-S160. 8

Pathophysiology of migraine associated with Ultrasound-Guided Foam

Sclerotherapy (UGFS)

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Pathophysiology of migraine with aura (AM)

Extensive cortical depression (propagated):

Depolarization wave from the occipital cortex to the forehead (may be limited): occipital = visual troubles parietal = paresthesias frontal = speech troubles

Endothelin-1 (powerful vasoconstrictor) = triggers AM

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Endothelin and foam

Varicose vein endothelium is damaged by foam and releases endothelin-1, which reaches the cerebral cortex via the PFO, triggering an aura.

Visual disturbances are not transient ischemic attacks

Visual

disturbances=

AM

Foam →release

of endothelin-1

Gillet et al. Phlebology. 2010;25:261-266. Frullini et al. Phlebology. 2011;26:203-208.11

According to expert recommendations:

MIGRAINE WITH OR WITHOUT AURA IS NOT A

CONTRAINDICATION FOR UGFS

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Breu FX, Guggenbichler S, Wollmann JC. 2nd European consensus meeting on foam sclerotherapy 2006. Tegernsee, Germany: Vasa 2008;S/713-729.

Berridge D, Lees T, Earnshaw JJ. The VEnous Intervention (VEIN) project. Phlebology. 2009;24 (suppl 1):1-2.

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LITERATURE REVIEW

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• 1023 articles analyzed• 41 articles retained reporting the presence of

stroke, transient ischemic attacks (TIA) or visual or speech disturbances, migraine, cephalalgia (63% foam and 37% liquid)

12 cases of stroke 9 TIAs 29 cases of migraine (0.27%)

Sarvananthan T, Sheperd AC, Willenberg T, Davis AH. Neurological complications of sclerotherapy for varicose veins. J Vasc Surg . 2012;55:243-251.

No personal history of migraine described

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There are insufficient data to determine the role of:

The technique used to generate foam, The gas used,

The volumes injected, The type of veins treated,

The different types of measures taken to avoid complications

• « The pathologic mechanisms resulting in CVA are likely to be different to those leading to migraine and visual disturbances » 

• « Precautions should be exercised particularly in patients with a known PFO and perhaps those known to suffer from migraine »

Sarvananthan T, Sheperd AC, Willenberg T, Davis AH. Neurological complications of sclerotherapy for varicose veins. J Vasc Surg 2012; 55:243-251.

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PRACTICAL RECOMMENDATIONSA symptomatic PFO is a contraindication for UGFS A personal history of migraine is not a contraindication for UGFS. However, it must be reported along with the presence or absence of aura Should migraine with/without aura occur after UGFS:

• Treat the patient with his/her usual antimigraine treatment (or with NSAI)

• In case of VDs, do not let the patient drive unaccompanied until the cessation of disturbances

• The risk/benefit ratio should be reviewed before continuing sclerotherapy treatment (preventative antimigraine treatment?)

In case of stroke: assessment (Doppler examination of the supra-aortic vessels, consultation with a neurologist, consultation with a cardiologist, MRI); pharmacovigilance report.

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CONCLUSION

• Neurological disturbances after UGFS should not be overlooked; however, they are usually AM variants

• Strokes are rare side-effects and are not the result of the same underlying mechanisms; no link with a personal history of migraine has been established; stroke diagnosis must be confirmed

• Currently, a history of migraine is not a contraindication for UGFS though it may contribute to the development of AM (or AM variant)

• Further studies are needed

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