Migraine in Patients Undergoing PFO (Patent Foramen Ovale) Closure: Evaluation of a Platelet-associated Pathophysiologic Linking Mechanism
Phase: NA
Conditions: Platelet Aggregation, Spontaneous, Migraine With Aura, Patent Foramen Ovale
Sponsor: Centro Cardiologico Monzino

MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR THE 
DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
Protocol number 
NCT03521193 
 
 
 
1 
 
 
Protocol number 
NCT03521193 
 
 
 
 
Sponsor: 
Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, S.p.A. 
Via C. Parea 4, 20138 Milano 
Tel: 0258002031 
Fax: 0258002623 
 
 
 
Title of Protocol: 
 
MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR THE 
DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
 
Site: 
Centro Cardiologico Monzino, Istituto di Ricovero e Cura a 
 Carattere Scientifico, S.p.A. 
 
Comitato Etico del Centro Cardiologico Monzino 
 
 
 
 
 
Principal Investigators: 
 
Dott.ssa Daniela Trabattoni, 
Responsabile U.O. Cardiologia Invasiva 3 e Women Heart Center, 
CCFM 
 
 
 
 
 
 
Versione n° 01 Data 00.00.0000 

MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR THE 
DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
Protocol number 
NCT03521193 
 
 
2 
 
INDEX 
 
0. 
INVESTIGATOR AGREEMENT ................................................................................................ 4 
1. 
IGENERAL INFORMATION .......................................................................................................... 5 
2. 
BACKGROUND AND RATIONAL .................................................................................................... 6 
3. 
OBJECTIVES AND AIMS OF THE STUDY .......................................................................................... 7 
4. 
STUDY DESIGN ........................................................................................................................ 8 
4.1 PRIMARY AND SECONDARY OUTCOMES ....................................................................................................... 8 
4.2  
STUDY DESIGN ............................................................................................................................. 8 
4.2.1 Schematic diagram of the study design ................................................... Errore. Il segnalibro non è definito.9
 
 ............................................................................................................. Errore. Il segnalibro non è definito. 
4.3 MEASURES TAKEN TO MINIMISE SYSTEMATIC ERRORS .......................................................................................... 8 
4.4 TREATMENT UNDER STUDY (IF APPLICABLE) .................................................................................................. 8 
4.5 EXPECTED DURATION OF THE SUBJECT'S PARTICIPATION ....................................................................................... 8 
4.6 RULES FOR INTERRUPTION (IF APPLICABLE) ..................................................................................................... 8 
4.7 PROCEDURES FOR CHECKING THE RELIABILITY OF THE EXPERIMENTAL PRODUCT (IF APPLICABLE) ........................................... 9 
4.8 PRESERVATION OF RANDOMIZATION CODES AND PROCEDURES FOR DECODING (IF APPLICABLE) ............................................ 9 
4.9 EVALUATION PARAMETERS .................................................................................................................... 9 
5. 
SELECTION AND WITHDRAWAL OF PATIENTS .................................................................................. 9 
5.0 CHARACTERISTICS OF THE POPULATION ......................................................................................................... 9 
5.1 INCLUSION CRITERIA ........................................................................................................................... 9 
5.2 EXCLUSION CRITERIA ........................................................................................................................... 9 
5.3 CRITERIA FOR WITHDRAWAL ..................................................................................................................... 9 
5.4 INFORMED CONSENT ........................................................................................................................ 10 
6 
TREATMENT OF PATIENTS ........................................................................................................ 10 
6.1 TREATMENT/PROCEDURES AND EVALUATIONS PLANNED DURING THE STUDY .............................................................. 10 
6.2 TREATMENTS/DRESSINGS PERMITTED AND NOT BEFORE/DURING THE TRIAL ......................................................................... 1213
 ..................................................................................................................................................................................... 12 
6.3 PROCEDURES TO MONITOR PATIENT COMPLIANCE (IF APPLICABLE) ......................................................................... 13 
7. 
EFFICACY/ENDPOINT EVALUATION ............................................................................................. 13 
7.1 SPECIFYING EFFECTIVENESS/ENDPOINT PARAMETERS ....................................................................................... 13 

MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR THE 
DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
Protocol number 
NCT03521193 
 
 
 
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7.2 METHODS AND TIMING FOR THE ASSESSMENT, RECORDING AND ANALYSIS OF EFFICACY PARAMETERS ........................................ 1313
 ..................................................................................................................................................................................... 13 
8. 
SAFETY/TOLERABILITY ASSESSMENT ........................................................................................... 13 
8.1 SPECIFYING SECURITY PARAMETERS .......................................................................................................... 13 
8.2 METHODS AND TIMES FOR THE ASSESSMENT, RECORDING AND ANALYSIS OF SAFETY PARAMETERS ....................................... 13 
8.3 PROCEDURES FOR REPORTING FOR THE REGISTRATION AND REPORTING OF ADVERSE EVENTS AND INTERCURRENT DISEASESI .......... 13 
8.4 TYPE AND DURATION OF FOLLOW-UP OF SUBJECTS FOLLOWING ADVERSE EVENTS ......................................................... 13 
9. 
STATISTICAL ANALYSIS............................................................................................................. 13 
9.1 STATISTICAL ANALYSIS .......................................................................................................................... 13 
9.2 CALCULATION OF THE NUMBER OF SAMPLES: ................................................................................................ 13 
9.3 SIGNIFICANCE LEVEL TO BE USED ................................................................................................................................. 1314
 ..................................................................................................................................................................................... 13 
9.4 CRITERIA FOR THE CONCLUSION OF THE TRIAL ................................................................................................ 14 
9.5 STEPS TO HANDLE MISSING, UNUSED, OR SPURIOUS DATA ................................................................................... 14 
10. DIRECT ACCESS TO ORIGINAL DATA AND DOCUMENTS .................................................................... 14 
11. QUALITY CONTROL AND ASSURANCE PROCEDURES .......................................................................... 14 
12. ETHICAL ASPECTS .................................................................................................................. 14 
13. DATA RETENTION AND ANALYSIS ............................................................................................... 14 
14. PRIVACY ............................................................................................................................. 14 
15.  INSURANCE ......................................................................................................................... 14 
16. PUBLISHING POLICY ............................................................................................................... 15 
17.  INTELLECTUAL PROPERTY ....................................................................................................... 14 
18. ADMINISTRATIVE REQUIREMENTS ............................................................................................. 15 
19 
SELECTED BIBLIOGRAPHY ........................................................................................................ 16 
 

MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR THE 
DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
Protocol number 
NCT03521193 
 
 
4 
 
0. 
Investigator Agreement 
 
I declare that I have read and approved the protocol set out in this document. 
 
I am aware of the responsibility to be assumed as an investigator in accordance with the provisions 
of the rules of Good Clinical Practice, the Declaration of Helsinki, and the study protocol and I 
undertake to conduct the study according to the aforementioned directives and to direct and assist 
the study staff assigned by me. 
 
 
Principal Investigator:  
 
 
 
Sign ______________________________________________    Date: ______________________ 
 
 
 
 
 

MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR THE 
DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
Protocol number 
NCT03521193 
 
 
 
5 
 
 
1. 
General information 
 
Title: MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR 
THE DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
 
Version number: 01 
Data: 09.05.2018 
 
Sponsor: 
CENTRO CARDIOLOGICO MONZINO S.p.A., ISTITUTO DI RICOVERO E CURA A 
CARATTERE SCIENTIFICO 
    
 
Via C. Parea, 4 – 20138 Milano 
 
Principal investigator: 
 
Daniela Trabattoni, MD 
 
CENTRO CARDIOLOGICO MONZINO S.p.A. 
 
    
 
ISTITUTO DI RICOVERO E CURA A CARATTERE SCIENTIFICO 
   
 
 Via C. Parea, 4 – 20138 Milano 
 
    
 
Tel: 02 58002334 
 
 
 
Fax: 0258002623 
 
Co-Investigators 
Marina Camera, PhD; Giovanni Teruzzi, MD; Sarah Troiano, MD; Marta Brambilla, PhD; Laura 
Rossetti, PhD. Viviana Cavalca, PhD. 
 
Sede di svolgimento: 
Centro Cardiologico Monzino, S.p.A., IRCCS 
Via C. Parea, 4 
20138 Milano 
 
Conservazione dei campioni biologici 
Le determinazioni ematochimiche saranno effettuate presso il laboratorio Analisi e il laboratorio di 
Ricerca del Centro Cardiologico stesso.  

MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR THE 
DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
Protocol number 
NCT03521193 
 
 
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2. 
Background and rational  
 
Background 
Migraine is a primary disorder of multifactorial etiology 1  with a prevalence in the United States of 
28 million people (13%) which result in affected with a consequent economic burden on the health 
system.  
Numerous studies have documented a significant association between migraine, especially migraine 
with aura, and the presence of perviety of the oval foramen8. 
Symptomatic patients for migraine with aura have a higher prevalence of PFO than migraines 
without aura and patients who do not suffer from migraine 4  and have a 4.5 times higher probability 
of encountering a 50% reduction in the frequency of migraine attacks after PFO closure compared 
to symptomatic subjects for migraine without aura  7. 
The oval foramen remains pervious after birth in about 20% of the population and predominantly in 
female subjects. Closure of the oval foramen pervio (PFO) resulted in a partial or complete 
regression of migraine symptomatology in several retrospective and monocentricstudies 4–6. In these 
studies, percutaneous correction of PFO had been performed for the secondary prevention of stroke  
4  or for the presence of conditions related to intracardiac shunt such as decompression sickness in 
divers  6. Since there are no diagnostic or provocative tests capable of correlating PFO to migraine, 
it is difficult to understand which patients will be responsive to the elimination of the right-left 
intracardiac shunt after correction of PFO.  
Other possible clinical benefits of PFO closure include reducing the sequalities of a paradoxical 
embolism such as ischemic stroke, myocardial infarction11, 12  and cognitive impairment. 
Although it has not been documented, the prevention of chronic headache through the correction of 
PFO in the earliest and phase phase of the disease can also be beneficial. Current estimates indicate 
that 4% of the general population suffers from chronic migraine 13  which in 75% of cases is the 
result of a transformation from a phasic or periodic migraine. 14. Eradication of the source of 
migraine can also be positive against these progressive pathological processes. However, to date, 
international guidelines (ESC and AHA/ACC) do not include migraine among the indications to the 
correction of PFO. 
 
he prevalence of PFO in subjects with migraine with aura varies between 41% and 89%4  , while it 
is between 7% and 34% in symptomatic patients for migraineswithout aura and between 20% and 
25% in controls without migraine  4  . 
This association is two-way because the risk of developing a neurological ischemic event in a 
subject with PFO and migraine is 5.1 times higher (95% CI, 4.67 -5.59) than in a subject without 
PFO 9 and young women are more frequently symptomatic for migraine when affected by PFO. 
In women and patients with stable coronary artery disease, in antiplatelet therapy with aspirin, high 
platelet reactivity (HAPR) or resistance to aspirin has been described, which is associated with 
unfavorable clinical outcomes. A study conducted by Jesurum et al, suggested that subjects with 
migraine have a higher prevalence of HAPR than healthy subjects or patients with stable coronary 
artery disease being treated with aspirin 325 mg. However, the clinical implications of HAPR in 
subjects with emicrania and PFO require further investigation of analysis for the high risk of 
cerebral stroke and myocardial infarction and highlight the need to prescribe preventive antiplatelet 
therapy early. 

MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR THE 
DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
Protocol number 
NCT03521193 
 
 
 
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In addition, the extent of the right-left shunt as assessed and measured at the transcranial Doppler 
also increases progressively from the migraine-free control groups, to the migraineranics without 
aura and in those with aura 17  . 
Recent studies have shown that a prominent Eustachian valve and a Chiari network, as an 
embryonic residue in the right atrium, are more often detectable in migraine patients with aura 
(100% in migraine with aura vs 55% in non-migraines)19.20  and this could explain the increase in 
dx-sin shunt. In addition, an analysis of the anatomy of the interatrial septal (SIA) showed the 
presence of SIA aneurysm in 13% of patients with migraine compared to 1.9% of control subjects 
(p=0.05)21. In addition, among migraine patients, SIA aneurysm was predominantly observed in 
subjects with aura (28%) compared to those without aura (3.6%) 21. 
 
Rational 
The premium (Prospective, Randomized Investigation to Evaluate Incidence of Headache 
Reduction in Subjects With Migraine and PFO Using the AMPLATZER PFO Occluder to Medical 
Management) study hypothesis was based on the possible significant reduction in the frequency of 
migraine attacks with and without aura after percutaneous correction of PFO and broad dx-sin shunt 
in patients symptomatic for migraine from 6 to 14 days/month and not responsive to drug therapies.  
The primary endpoint of the studywas  to reduce the frequency of migraine attacks (with or without 
aura) by at least 50%; the proportion of patients with headache reduction was superimposable in the 
PFO correction group (38.5%) and in that addressed to medical therapy (32%), p=0.32. With regard 
to secondary endpoints, there was a significant reduction in the number of migraine days/month 
after CORRECTION of PFO compared to the control group (: –3.4 ±4.4 days versus –2.0 ±5.0 days 
(p = 0.025). No difference was observed in the percentage of patients who achieved a  75% 
reduction > migraine attacks while a very significant difference was observed with regard to 
subjects who experienced a complete regression of migraine episodes: 8.5% (10/117) in the PFO 
correction group vs 1.0% (1/103) in the medical therapy group (p=0.01). Among these patient 
responders, 6 were symptomatic for migraine with aura while the other 4 were migraines with 
isolated episodes of aura.   
It could be speculated that the etiological mechanism of headache in patients not subjected to PFO 
closure could be the activation of platelets inside the tunnel, the overlap between septum primum 
and secundum, of the patent foramen ovale. This segment, which may be characterized by a 
potential flow turbulence between the two septa, could lead to platelet activation, especially in the 
presence of SIA aneurysm. In a small group of patients with migraine, resistance to aspirin has been 
documented in 24% of subjects, suggesting platelet hyper-reactivity.  
Clopidogrel and aspirin are more effective than aspirin alone in reducing headache, exacerbated 
after percutaneous correction of PFO in the first follow-up period24  to demonstrate that platelet 
microaggregates may be responsible for post-closure migraine of PFO and may play a central role 
in the genesis of headache. 
In women and patients with stable coronary artery disease, in antiplatelet therapy with aspirin, high 
platelet reactivity (HAPR) or resistance to aspirin has been described and is associated with adverse 
clinical outcomes. A study conducted by Jesurum et al, suggested that subjects with migraine have a 
higher prevalence of HAPR than healthy subjects or patients with stable coronary artery disease 
being treated with aspirin 325 mg. However, the clinical implications of HAPR in subjects with 
migraine and PFO require further investigation of analysis for the high risk of cerebral stroke and 
myocardial infarction and the need to prescrivere early prevention therapy.  
A PFO with dx-sin shunt should require a neurological substrate susceptible and vulnerable to some 
substance that by-passes the pulmonary circle and induces headache. The endothelium of the 

MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR THE 
DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
Protocol number 
NCT03521193 
 
 
8 
pulmonary circle has significant metabolic activity.  The lung in fact metabolizes, activates or 
inactivates many compounds including vasoactive amines and other humoral substances25. 
Prostaglandins E1, E2 and F2 are completely removed from the bloodstream; serotonin is removed 
between 85% and 95%; 70% of angiotensin I is converted to angiotensin II, and 80% of bradykinin 
is inactivated  26. It is not known whether these substances may increase the susceptibility of the 
brain to stimulate environmental or intrinsic triggers capable of triggering migraine 
 
. 
Objectives and aims of the study 
The aim of the study is to verify whether vasoactive/inflammatory substances together with 
increased platelet reactivity may play a key role in the onset of migraine and in its maintenance 
even after correction of PFO. The morphological and anatomical characteristics of the oval fossa 
will also be analyzed in order to identify elements that can correlate with increased platelet 
reactivity and predict a clear benefit in the control of migraine symptoms after correction of PFO. 
The analysis will also be extended to the evaluation of differences between female and male sex.  
 
4. 
Study design 
 
1. 
4.1 
Primary and secondary outcomes 
 
Primary outcomes: 
Evaluation of the % regression of migraine episodes with aura in relation to platelet reactivity in 
migraine patients, with and without aura, carriers of PFO, together with the dosage of PGE1, PGE2, 
serotonin and cytokines in order to identify potential predictive markers of beneficial effect of PFO 
correction on migraine symptoms.  
 
Secondary outcomes 
1. 
Reduction in the number of migraine days compared to pfo pre-correction, FU at 6 and 12 
months. 
 
4.2  
Study design 
 
The study is prospective observational, monocentric  
 
4.3 Measures taken to minimise systematic errors 
 
4.4 Treatment under study (if applicable) 
 
4.5 Expected duration of the subject's participation 
12 months  
4.6 Rules for interruption (if applicable) 
 

MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR THE 
DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
Protocol number 
NCT03521193 
 
 
 
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4.7 Procedures for checking the reliability of the experimental product (if applicable) 
 
4.8 Preservation of randomization codes and procedures for decoding (if applicable) 
 
4.9 Evaluation parameters 
The data will be stored on electronic support. All the data reported in the data collection sheet have 
been obtained from the original documents and agree with the latter. The list of the individual data 
collected is shown in the "data collection sheet", attached to this document. (excel file) 
 
5. 
Selection and withdrawal of patients 
 
5.0 Characteristics of the population 
 
The study population includes patients with patent foramen ovale and previous neurological event 
(TIA or stroke) with clinical indication to the percutaneous correction of the defect according to 
guidelines or ina previous TIA/stroke absence when addressed to the pfo treatment  for migraine 
non responsive to specific therapy,as per the evaluation of the neurologist specialist. Similar 
evaluations are not currently available in the literature able to identify patients who, not responsive 
to specific drug therapy, as prescribed by the neurologist specialist, and carriers of PFO, can be 
directed to the percutaneous correction of the defect with indication at the moment "off-label" with 
respect to what is codified by the international guidelines (ESC and AHA / ACC) but potentially 
effective in the control of symptomatology. The advantage of PFO correction observed so far only 
in patients undergoing PFO correction as a result of cerebral ischemic events, could translate into 
migraine workers in a reduction in costs borne by the National Health System in the number of 
neurological medical examinations, pharmacological prescriptions and missed working days. 
 
 
5.1 
Inclusion criteria 
Patients aged > 18 years will need to meet 2 or more criteria: 
1. 
previous Stroke o TIA 
2. 
Positive MRI for ischemic outcomes – 
3. 
presence of PFO with dx-sin shunt in basal conditions > 10 MES and during Valsalva > 20 
MES 
4. 
SIA aneurysm or residual Chiari network/Eustachian valve 
5. 
 Positive Thrombophylic screening (MTHFR/prot C/Prot S) 
6. 
ability to sign informed consent for participation in the study and adhere to the planned 
clinical follow-ups  
5.2 
Exclusion criteria 
1. 
Patients aged > 70 years 
2. 
Presence of paroxysmal atrial fibrillation 
3. 
TSA vasculopathy  
4. 
LV Systolic function  < 30% 
5. 
Moderate/severe mitral valve failure 

MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR THE 
DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
Protocol number 
NCT03521193 
 
 
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6. 
Allergy or intolerance to antiplatelet therapy 
7. 
Allergy to nickel 
8. 
Severe renal failure (GFR < 30 ml/min) 
5.3 Criteria for withdrawal  
 
5.4 
Informed consent 
It is the responsibility of the researcher to obtain written informed consent from the 
participants before inclusion in the study, after a full explanation of the nature, objectives 
and risks inherent in participation in the study. The methods of processing personal data and 
clinical information obtained will also be explained to each participant; the participants in 
the study will sign the consent to the processing of personal data. It will also be emphasized 
that participation in the study is voluntary and it will be possible to interrupt it at any time or 
request at any time the elimination of any biological information or material obtained for 
research purposes.  
 
6 
Treatment of patients 
1. 
6.1 Treatment/Procedures and evaluations planned during the study  
 
The study, which will take place at the Invasive Cardiology unit and cardiovascular cell and 
molecular biology,at the Monzino Cardiology Center IRCCS, will be divided into two phases, 
described below.  
 
Step 1: Screening of symptomatic PFO patients for migraine with aura initiated 
percutaneous PFO correction and clinical follow-up.  
Estimated time: 24 months  
 
This phase of the study aims to test the hypothesis that the population of subjects with PFO 
and indication to percutaneous correction of the defect, when symptomatic for migraine with 
or without aura, can be characterized as responders or non-responders with regression of the 
migraine symptomatology / aura. 
The identification of symptomatic patients for migraine, after preliminary neurological 
evaluation, will be accompanied by a classification of migraine according to the severity 
scale of migraine sec. Anzola (Table 1). This evaluation will be repeated after PFO 
correction and outpatient clinical follow-up at a distance of 6 and 12 months, together with 
the execution of color-Doppler TT echocardiogram. This last examination will characterize 
the correct positioning of the PFO occlusive device and the presence/absence of residual 
inter-atrial shunt dx-sin.  
TABLE 1. Migraine Severity Score 
 
Intensity 
    0=No pain 
    1=Moderate (does not interfere with the performance of daily activities)  
    2=Severe (interferes with the performance of daily activities) 
                3=Inbearable (riquires enticing) 
Duration 

MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR THE 
DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
Protocol number 
NCT03521193 
 
 
 
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    0=No pain 
    1=<6 hours 
    2=6–12 hours 
    3=>12 hours 
Frequency 
    0=No pain 
    1=1–4/month 
    2=5–9/month 
    3=>10/month 
Aura 
    0=No aura 
 
 
OCCLUDER DEVICE FOR PFO 
1. 
The Occlutech Figulla device consists of a single layer of nitinol meshes that conform to 
give rise to 2 flexible discs (the left disc withdia metro smaller than 2 mm) with a perno only 
on the right side. The discs are connected to each other thanks to a flexible and compressible 
central portion the size of 3 mm. The left disc is a flat monolayer covered with an ultra-thin 
piece of polyethylene terephthalate. The size of the Figulla device is determined by the 
diameter of the two discs in the following configurations: 16/18, 23/25, 27/30 and 31/35 
mm.  
 
PFO CORRECTION PROCEDURE 
1. 
Pfo correction will be performed percutaneously under local anesthesia with bilateral 
femoral venous puncture by placement of introducer 6F in the right femoral vein and 8F in 
the left femoral vein. The 8F introducer will be replaced at sin with the placement of 45-
cm,8.5 F Slow-curve introducer for the advancement of the intracardiac ultrasonographic 
catheter (Ultra ICETM,Boston Scientific, Marlborough, MA, USA). This probe, with the 
advantage of avoiding the intubation of the patient, will allow to characterize the anatomy of 
the SIA and allow the measurements of the oval fossa and the presence / absence of 
aneurysm of the SIA for the most appropriate choice of the occlusive device suitable for size 
and to monitor the positioning and implantation of the occlusive device.  A 0.035" guide 
wire with J tip will be positioned through the inteartrial septa into the superior pulmonary 
vein. In all cases an occlusive device of adequate size will be loaded inside a moon cannula 
of the size between 7-10 F and advanced pushing the release cable to the end of the 
introducer positioned in the left atrium. Under fluoroscopic and intracardiac ultrasound 
guidance, the left disc of the device will be implanted and approached against the left side of 
the SIA. With a slight voltage maneuver on the release cable, the cannula will be retracted 
allowing the right disc to be implanted. The intracardiac ultrasound evaluation will allow to 
evaluate the correct positioning of the device and the absence of images related to coronary 
obstruction and / or pulmonary venous return or compression of the aortic root and 
atrioventricular valves. At this point the device will be permanently released.  
INTRA E POST-PROCEDURE THERAPY 

MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR THE 
DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
Protocol number 
NCT03521193 
 
 
12 
Patients will receive 70 IU/Kg of heparin at the beginning of the procedure in order to 
maintain the ACT (activated platelet aggregation time) value > 200 seconds. Aspirin 100 mg 
will already be therapy in place for more than 7 days and continued for at least 6 months 
after the correction of PFO while Clopidogrel 75 mg will be administered immediately after 
the procedure and continued for 2-3 months in patients treated with implantation of devices 
> 25 mm diameter. Antibiotic prophylaxis will be started before the procedure and continued 
for the next 5 days.  
FOLLOW-UP 
The clinical and diagnostic follow-up with cardiological examination, color-Doppler 
echocardiogram at 6 and 12 months and compilation of the Migraine severity score scale 
(Table 1), will allow to evaluate any residual shunts post correction of PFO and the 
beneficial effects on the control of migraine symptoms by reassessment of the Anzola score. 
 
 
Phase 2: Analysis of platelet reactivity and levels of inflammatory cytokines,PGE1, 
PGE2 and serotonin in migraine patients with PFO. 
Estimated time: 24 months 
 
This phase of the study aims to investigate whether the beneficial effect of PFO correction on 
migraine is secondary to a barrier mechanism to platelet microembolization and that this response 
may correlate with the parameters of platelet function and activation.  For this purpose, the study of 
platelet function will be carried out before the correction of PFO and 180  days after surgery. 
For the evaluation of the parameters of platelet function from each patient, a blood sample will be 
taken in the absence of stasis, in order to avoid platelet activation, from the antecubital vein of the 
forearm by means of a G19 needle. Before proceeding with the separation of the platelets, a 
quantitative hematology analysis will be performed with leukocyte formula and platelet count by 
means of Sysmex XS 1000 automatic blood count. 
Cytofluorimetry studies will allow to characterize the state of platelet activation in terms of protein 
expression both on the cell surface and inside the cell. In particular, the expression of P-selectin, 
activated GpIIbIIIa, Tissue Factor and Phosphatidylserine will be evaluated through the use of 
specific monoclonal antibodies. These analyses will be performed both in basal conditions and after 
in vitro activation with agonists such as ADP, thrombin and epinephrine. The same conditions will 
also be used for the evaluation of the presence of mixed aggregates, platelet-leukocytes, sensitive 
index of platelet activation. 
PRP (Platelet-Rich Plasma), separated from the blood by centrifugation, will be used to perform 
platelet aggregation studies in response to different agonists such as ADP, collagen, thrombin, 
epinephrine and arachidonic acid. 
The characterization of the circulating microvesicles will be performed on samples of Platelet-Free 
Plasma (PLP), by means of a multiparametric analysis performed using the new generation 
cytofluorimeters. In particular, not only the total number of microvesicles present in the sample will 
be considered, but a detailed phenotyping will be performed that will give information on the 

MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR THE 
DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
Protocol number 
NCT03521193 
 
 
 
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cellular derivation of the microvesicles, considering in particular those of platelet, leukocyte and 
endothelial origin.  
Serum TXB2 levels and urinary excretion of 11-dehydro-TXB2  will be evaluated by mass 
spectrometry. 
The levels of the inflammatory cytokines IL-1, IL-6, TNFa will be measured on plasma samples 
with enzyme immunoassay, while the levels of PGE1,PGE2 and serotonin will be dosed by HPLC 
method. 
 
6.2 Treatments allowed and not before/during the trial 
 
6.3Procedures to monitor patient compliance (if applicable) 
 
7. 
Efficacy/endpoint evaluation 
 
7.1 Specifying Effectiveness/Endpoint Parameters 
Primary endpoints: 
 
Secondary endpoints 
 
7.2 Methods and times for the assessment, recording and analysis of effectiveness parameters 
 
8. 
Safety/tolerability assessment 
8.1 Specification of safety parameters 
 
8.2 Methods and times for the assessment, recording and analysis of safety parameters 
 
8.3 Procedures for reporting for the registration and reporting of adverse events and intercurrent 
diseases 
 
8.4 Type and duration of subjects following adverse events 
 
9. 
statistical analysis 
9.1 statistical analysis 
Continuous variables will be summarized using the DS ± mean. Categorical variables are 
represented using frequencies and percentages. For the comparison between responders andnon-
responders,the Student's 2-code t-test or the Wilcoxon test for continuous variables will be used. 
The Chi-square test or the Fisher test will beused forcategorical variables. 
 
9.2 Calculation of the sample number 
The sample size calculation is based on the 1-year primary endpoint. A value for the frequency of 
reachingtheprimary endpoint was placed around 60%, in accordance withthe data reportedin 

MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR THE 
DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
Protocol number 
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literature22, 27. A sample of 92 patients was identified, necessary to obtain a potencyof 80% able to 
detect as significant (p<0.01, considering the Bonferroni correction for multiple tests) a correlation 
coefficient of 0.35 (adjusted for 4 confounding variables) between the variation of the migraine 
score sec. Anzola and any of the 5 factors (platelet reactivity, PGE1, PGE2, cytokines, serotonin) 
measured at baseline. 
 
9.3 Significance level to use 
Statistical significance will be considered that obtained with a p value of 0.05. 
 
9.4 Criteria for the conclusion of the trial 
 
9.5 Steps to handle missing, unused, or spurious data 
 
10. 
Direct access to original data and documents 
The investigator will allow monitoring, verification, review by the Ethics Committee or any other 
control body, allowing direct access to the original data and documents. 
 
11. Quality Control and Assurance Procedures 
Regular internal monitoring visits will be carried out. 
 
12. 
Ethical Aspects 
The Study will be conducted in full respect of human dignity and its fundamental rights as dictated 
by the "Treaty of Helsinki" and subsequent amendments, by the "Good Clinical Practice" (GCP) 
rules issued by the European Community and in accordance with all local laws and regulations 
concerning clinical trials. 
 
13. 
Data retention and analysis 
Sensitive data, managed on computer support, will be processed as per current legislation and 
therefore the personal information will be separated from those that determine a clinical picture of 
the patient. The original data will be kept for 7 years by the investigators and, on request, made 
public. The reference that links the clinical data to a patient will be kept in a Microsoft Excel format 
file on the personal computer of the project coordinator. The patient's personal data are not of 
interest for the trial in question. 
 
14. Privacy 
The researcher undertakes to obtain and record on paper or computer and in a clear manner the 
information required in this protocol and to ensure safe storage and confidential access to 
information. The patient's surname(s), first name(s) and date of birth will only be present in the 
source document (medical record). Each biological information or material will be identified with a 
unique code that will allow to associate the clinical data with the laboratory results but, in no case, 
with the identity of the patient. 
 
15. Insurance 
For the risks deriving from participation in the study, the Monzino Cardiology Center, IRCCS has 
an adequate insurance coverage stipulated in accordance with the laws in force on the subject. By 
contract, the insurance will respond only in cases where the damage suffered by the patient is 
related to any procedure associated with his participation in the study. The insurance will not 

MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR THE 
DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
Protocol number 
NCT03521193 
 
 
 
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reimburse damages resulting from procedures conducted by the patient not covered by this Protocol. 
 
16.Publication criteria 
The results of the study will be used by the investigators only within the objectives indicated in the 
protocol.  
 
17. 
 Intellectual property 
All publications and /or communications related to the study will be previously approved by the P.I. 
of the Institution involved and in particular by the PI Dr. Daniela Trabattoni  of the Monzino 
Cardiology Center. 
The product of data processing in connection with this Study, including documentation, 
information, materials and results in any form generated in the course of the study, will be the 
property of the investigators.  
 
18.Administrative requirements 
Beginning of the study 
The study will begin only after the written approval of the Ethics Committee. 
 
Standards of Good Clinical Practice and European Directives for Clinical Trials 
The investigators assure that the study will be conducted in accordance with the Helsinki 
Declaration (1964), Amendment of Sommerset West, South Africa (1996) and with the international 
standards of standards of Good Clinical Practice, of the ICH (International Conference on 
Harmonization) and in accordance with all local laws and regulations concerning clinical trials. The 
study will not begin until there is approval, by the Ethics Committee, of the protocol, the 
information sheet for the subjects, the consent procedure and the written informed consent form. 
 
Amendments to the Protocol 
Any proposed amendment will only be implemented if approved by the Ethics Committee 
 
confidentiality 
The investigators involved are committed to preserving the confidentiality of the patients taking 
part in the study. 
 
responsibility 
The person responsible for the processing of the personal data of the participants in this study is Dr. 
Massimo Castoldi, Medical Director of the Monzino Cardiology Center, IRCCS. 
 
The scientific manager of this study at the Monzino Cardiology Center, IRCCS is Dr. Daniela 
Trabattoni, Head of U.O. Invasive Cardiology 3 and Women Heart Center 
 
The statistical manager of this study is Dr. Fabrizio Veglia, biostatistician at the Monzino 
Cardiology Center, IRCCS. la Direzione Scientifica 
 
Conflict of interest 
Researchers involved in this project declare the absence of conflicts of interest. 
 

MIGRAINE IN PATIENTS WITH PATENT FORAMEN OVALE: IDENTIFICATION OF A RISK PROFILE FOR THE 
DEVELOPMENT OF AURA AND CEREBRAL ISCHEMIC EVENTS. The LEARNER Study 
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