Introduction and objectives Pulmonary arteriovenous malformations (PAVMs) are an example of a right-to-left shunt resulting in deoxygenated, unfiltered venous blood bypassing the pulmonary capillaries to re-enter the systemic arterial circulation. Patients with PAVMs are known to have an increased incidence of migraines, reducing following PAVM treatment by embolisation. This study aimed to examine if paradoxical embolism of particulate matter through PAVMs may precipitate migraines.
Methods A structured survey was designed for online completion by people with hereditary haemorrhagic telangiectasia (HHT), the most common cause of PAVMs. Question logic directed participants through a series of unbiased questions that asked about HHT features including presence of PAVMs; variables in relation to migraines; and whether participants had undergone imaging tests. Stratified by whether contrast had been given, participants reporting migraines were asked whether any difference in migraines had been noted following scans, by ticking that “migraines were no different really”; “seemed a bit better”; “seemed a bit worse”; “seemed to bring on a migraine”; “seemed to stop a migraine”. Participants were recruited from 26/07/2013- 21/04/2015, yielding 702 consented responses. Data were downloaded to an Excel spreadsheet for participant stratifications, and statistical analyses using GraphPad Prism 6.0 and STATA 13.1 (Statacorp LP).
Results Overall, 557 participants had HHT, of whom 180 (32.3%) reported features consistent with migraines. HHT participants with migraines more commonly reported PAVMs than those without migraines (62.8% vs 38.5%, p < 0.00001). For computerised tomography (CT) scans, images “with injection of contrast” were associated with a higher proportion of participants reporting worsening migraines than “without injection of contrast” CT scans (11.7% vs 3.4%, p = 0.0065). This association strengthened following paired analysis of participants who had undergone both methods (13.6% vs 3.2%, p = 0.0032). In multiple regression analyses, there was no additional contribution from other participant demographics such as alcohol consumption or smoking habit. Analysis of magnetic resonance imaging (MRI), contrast echocardiography and ultrasound data is ongoing.
Conclusion This study strongly indicates that an association between injecting contrast media and the worsening of migraines, in participants with right-to-left shunts due to PAVMs, exists. Further research is required to establish the exact mechanism responsible for this phenomenon.
*S1- BTS Medical Student Award Highly Commended.
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