Is ultrasound foam sclerotherapy
contraindicated
in patients with migraine?
By Claudine HAMEL-DESNOS, Caen, France
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Should we treat varicose veins using
UGFS* in patients with migraine?
Meier B et al. Eur Heart J 2012;33:705-713
Foam
*Abbreviations:
PFO, patent foramen ovale;
UGFS,
ultrasound-guided foam
sclerotherapy
Patent
foramen ovale
MIGRAINE
Neurological
disturbances?
2
« 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
3
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
Mostly case reports
Good recovery
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.
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What’s a migraine?
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The International Headache Society
migraine without aura: diagnostic criteria
A. 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
The International Headache Society
migraine with aura : diagnostic criteria
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.
3.
at least 1 aura symptom develops gradually over ≥5 min and/or diferent aura
symptoms occur in succession over ≥5 min
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 Classification of Headache Disorders. Cephalalgia. 2004;24:S9-S160.
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Pathophysiology of migraine
associated with UltrasoundGuided 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
Gillet et al. Phlebology. 2010;25:261-266.
Frullini et al. Phlebology. 2011;26:203-208.
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According to expert recommendations:
MIGRAINE WITH OR WITHOUT
AURA IS NOT A
CONTRAINDICATION FOR UGFS
12
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
No personal history of migraine described
 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.
15
16
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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 RECOMMENDATIONS
A 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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