Is ultrasound foam sclerotherapy contraindicated in patients with migraine?

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Is ultrasound foam sclerotherapycontraindicated
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 201233705-713
Foam
Patent foramen ovale
MIGRAINE
Abbreviations PFO, patent foramen
ovale UGFS, ultrasound-guided foam
sclerotherapy
Neurological disturbances?
3
 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. 201141521-525.
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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. 200794(8)925-936.
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Whats a migraine?
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The International Headache Societymigraine
without aura diagnostic criteria

• At least 5 attacks fulfilling criteria B-D
• Headache attacks lasting 4-72 hours (untreated or
  unsuccessfully treated)
• 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)
• At least one of the following symptoms
• Nausea and/or vomiting
• Photophobia and phonophobia
• Not attributed to another disorder

The International Classification of Headache
Disorders. Cephalalgia. 200424S9-S160.
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The International Headache Societymigraine with
aura diagnostic criteria

• At least 2 attacks fulfilling criteria B-D
• Aura consisting of at least 1 of the following,
  but no motor weakness
• fully reversible visual symptoms including
  positive features (eg, flickering lights, spots,
  or lines) and/or negative features (i.e, loss of
  vision)
• fully reversible sensory symptoms including
  positive features (i.e, pins and needles) and/or
  negative features (i.e, numbness)
• fully reversible dysphasic speech disturbance
• At least 2 of the following
• homonymous visual symptoms and/or unilateral
  sensory symptoms
• at least 1 aura symptom develops gradually over
  5 min and/or diferent aura symptoms occur in
  succession over 5 min
• each symptom lasts gt5 and lt60 minutes
• Headache fulfilling criteria B-D for migraine
  without aura begins during the aura or follows
  the aura within 60 minutes
• Not attributed to another disorder

The International Classification of Headache
Disorders. Cephalalgia. 200424S9-S160.
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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
Visual disturbances AM
Foam ?release of endothelin-1

• 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. 201025261-266.
Frullini et al. Phlebology. 201126203-208.
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According to expert recommendations

• MIGRAINE WITH OR WITHOUT AURA IS NOT A
  CONTRAINDICATION FOR UGFS

13
Breu FX, Guggenbichler S, Wollmann JC. 2nd
European consensus meeting on foam sclerotherapy
2006. Tegernsee, Germany Vasa 2008S/713-729.

• Berridge D, Lees T, Earnshaw JJ. The VEnous
  Intervention (VEIN) project. Phlebology. 200924
  (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)

No personal history of migraine described
Sarvananthan T, Sheperd AC, Willenberg T, Davis
AH. Neurological complications of sclerotherapy
for varicose veins. J Vasc Surg . 201255243-251.
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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

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•  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 55243-251.
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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