Is ultrasound foam sclerotherapy contraindicated in patients with migraine?

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?

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ÂŤ The results of NOMAS can be seen as the strongest evidence against an association between migraine or migraine with aura and PFO Âť 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.

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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.

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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); fully reversible dysphasic speech disturbance

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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

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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 l a u s M Vi A = s e c n a b r u t dis e s a e rel â&#x2020;&#x2019; 1 Foam othelind n e f o 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

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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 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.

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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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