Clopidogrel for Prevention of New-Onset Migraines After Transcatheter Atrial Septal Defect Closure

August 2022

People with hemodynamically significant atrial septal defect (ASD) often undergo transcatheter ASD closure. In some patients, however, migraine headaches begin within a few weeks after closure for unknown reasons. In addition, it is unclear as to how long new-onset migraines occur after ASD closure.

A double-blind, randomized clinical trial was previously conducted for clopidogrel, an antiplatelet therapy, concomitant with aspirin in patients undergoing transcatheter ASD closure. The investigators found that clopidogrel treatment for 3 months following the procedure was associated with a reduced incidence of migraine attacks.1 However, the optimal duration of clopidogrel treatment is not clear.

A new study by Wintzer-Wehekind and colleagues2 is a prespecified follow-up to the initial trial designed to determine whether the incidence or severity of migraine attacks increased after cessation of clopidogrel at 3 months. If so, clopidogrel may need to be administered for longer than 3 months.

Adults who received the clopidogrel or placebo in the first trial were included in the follow-up analysis.2 A total of 84 patients received clopidogrel for the first 3 months following ASD closure, and 87 received placebo. All patients also received aspirin as an antiplatelet therapy after ASD closure. Aspirin was continued in 55% of all patients up to 6 months and in 29% up to 12 months with no differences between groups.

For the patients in the follow-up study, the incidence of new-onset migraine was higher in the group that had received placebo (21.8%) compared with the group that had received clopidogrel (9.5%) at 3 months after ASD closure.2 Between 3 and 6 months, 6 (3.5%) patients had continued migraine attacks with no significant difference between groups. Of these, 5 were in the original placebo group. Between 6 and 12 months, 1.8% had continued migraine attacks with no significant difference between groups. Thus, most participants who had new-onset migraine attacks in the first 3 months were free of migraine by 12 months, regardless of whether they were treated with clopidogrel or placebo during the first 3 months.2

Between 3 and 6 months after ASD closure, 1 patient who had received clopidogrel and 1 patient who had received placebo had a new-onset migraine attack. No patients had new-onset migraine attacks between 6 and 12 months after ASD closure. None had a migraine attack that caused moderate or severe disability after the first 3 months.2

The results showed that a 3-month course of clopidogrel is associated with reduced incidence of new-onset migraine attacks for ≤1 year after ASD closure. Furthermore, the results for the placebo group demonstrated that migraine eventually subsided in most patients with migraine after ASD closure.2

“The results of this study provide further reassurance for patients (usually young adults in working age) receiving transcatheter ASD closure by demonstrating a low rate of migraine events beyond 3 months following transcatheter ASD closure and supporting the early discontinuation of clopidogrel therapy if administered,” the investigators concluded.

References

  1. Rodés-Cabau J, Horlick E, Ibrahim R, Cheema AN, et al. Effect of clopidogrel and aspirin vs aspirin alone on migraine headaches after transcatheter atrial septal defect closure: the CANOA randomized clinical trial. JAMA. 2015;314(20):2147-2154.
  2. Wintzer-Wehekind J, Horlick E, Ibrahim R, et al. 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. JAMA Cardiol. 2021;6(2):209-213.

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