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Interventional Cardiology

Migraine Intervention With STARFlex Technology (MIST) Trial

A Prospective, Multicenter, Double-Blind, Sham-Controlled Trial to Evaluate the Effectiveness of Patent Foramen Ovale Closure With STARFlex Septal Repair Implant to Resolve Refractory Migraine Headache

Andrew Dowson, MBBS, PhD; Michael J. Mullen, MBBS, MRCP, MD; Richard Peatfield, MD, FRCP; Keith Muir, MD, FRCP; Arif Anis Khan, MBBS, FCPS; Christopher Wells, MB, ChB, FRCA; Susan L. Lipscombe, MB, ChB, MRCP; Trevor Rees, MB, ChB; Joseph V. De Giovanni, MD, FRCP, FRCPCH, MOM; W. Lindsay Morrison, MD, FRCP; David Hildick-Smith, MD, FRCP; Giles Elrington, MD; W. Stewart Hillis, MB, ChB, FRCP, FRCS; Iqbal S. Malik, MA, MRCP, PhD; Anthony Rickards, MBBS, FRCP, FESC

From Kings College Hospital, London (A.D.); Royal Brompton Hospital, London (M.J.M., A.A.K, A.R); Princess Margaret Migraine Clinic Charing Cross Hospital, London (R.P.); Division of Clinical Neurosciences, University of Glasgow, Glasgow (K.M); Pain Research Institute, Liverpool (C.W.); Brighton and Sussex University Hospitals NHS Trust, Brighton (D.H.-S., S.L.L.); Hawthorn Surgery, Sutton Coldfield (T.R.); University Hospital, Birmingham (J.V.D.G.); Cardiothoracic Centre, Liverpool (W.L.M.); Barts and the London NHS Trust, London (G.E.); Western Infirmary, Glasgow (W.S.H.); and St Mary’s Hospital, London (I.S.M.), UK.

Correspondence to Dr Andrew J. Dowson, The King’s Headache Service, King’s College Hospital, Denmark Hill, London SE5 9RS, UK. E-mail dr.dowson{at}btopenworld.com

Received July 12, 2007; accepted December 6, 2007.

Background— Patent foramen ovale (PFO) is prevalent in patients with migraine with aura. Observational studies show that PFO closure resulted in migraine cessation or improvement in 80% of such patients. We investigated the effects of PFO closure for migraine in a randomized, double-blind, sham-controlled trial.

Methods and Results— Patients who suffered from migraine with aura, experienced frequent migraine attacks, had previously failed 2 classes of prophylactic treatments, and had moderate or large right-to-left shunts consistent with the presence of a PFO were randomized to transcatheter PFO closure with the STARFlex implant or to a sham procedure. Patients were followed up for 6 months. The primary efficacy end point was cessation of migraine headache 91 to 180 days after the procedure. In total, 163 of 432 patients (38%) had right-to-left shunts consistent with a moderate or large PFO. One hundred forty-seven patients were randomized. No significant difference was observed in the primary end point of migraine headache cessation between implant and sham groups (3 of 74 versus 3 of 73, respectively; P=0.51). Secondary end points also were not achieved. On exploratory analysis, excluding 2 outliers, the implant group demonstrated a greater reduction in total migraine headache days (P=0.027). As expected, the implant arm experienced more procedural serious adverse events. All events were transient.

Conclusions— This trial confirmed the high prevalence of right-to-left shunts in patients with migraine with aura. Although no significant effect was found for primary or secondary end points, the exploratory analysis supports further investigation. The robust design of this study has served as the model for larger trials that are currently underway in the United States and Europe.

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