Effect of Clopidogrel and Aspirin vs Aspirin Alone on Migraine Headaches After Transcatheter Atrial Septal Defect Closure: One-Year Results of the CANOA Randomized Clinical Trial
Wintzer-Wehekind J, Horlick E, Ibrahim R, Cheema AN, Labinaz M, Nadeem N, Osten M, Côté M, Marsal JR, Rivest D, Marrero A, Houde C, Rodés-Cabau J.
JAMA Cardiol. 2020 Sep 23:e204297. doi: 10.1001/jamacardio.2020.4297. Online ahead of print.
Take Home Points:
- New-onset migraines after ASD closure improve or resolve spontaneously within 6 to 12 months in most patients.
- No significant rebound effect is observed after clopidogrel cessation at 3 months suggesting that early discontinuation should be strongly considered.
Commentary from Dr. Konstantin Averin (Edmonton), catheterization section editor of Pediatric Cardiology Journal Watch: Approximately 15% of patients develop new-onset migraine headaches after transcatheter closure of secundum atrial septal defects (ASD) with nitinol-based devices. The Clopidogrel for the Prevention of New Onset Migraine Headache Following Transcatheter Closure of Atrial Septal Defects (CANOA) trial demonstrated that these migraines can be successfully treated with clopidogrel within the 3-month period after device implant. There are limited data on the longer-term outcomes of migraines related to ASD closure. The authors sought to use the same patient cohort to assess late-incidence and severity of migraine attacks after ASD closure and clopidogrel cessation up to 12 months post-procedure.
A total of 171 patients were included for analysis (84 – clopidogrel and 87 – placebo), of which 27 (15.8%) developed migraines in the first 3 months and 2 (1.2%) after the first 3 months (see Figure below). At 3 months, there were significantly more patients with migraine in the placebo group (21.8% v 9.5%, p = 0.03). Only 2 patients presented with new migraine headaches after 3 months (none after 6 months) and 6 had residual migraine at 6 months. Beyond 3 months, there were no significant differences (placebo v clopidogrel) in number of patients with persistent migraine headaches and new migraine headaches after 3 months.
The authors conclude that new-onset migraine headaches after ASD closure occurred early (within 3 months) and resolved or improved spontaneously within 6 to 12 months in most patients. Given the bleeding risks associated with dual antiplatelet therapy (DAPT), especially in older populations, it is important to limit the duration of DAPT. These data suggest that DAPT can be used successfully for 3 months post-ASD closure in patients who develop migraines. Future research should focus on identification of patients at risk for developing migraines post-ASD closure and longer term outcomes of persistent migraines.