手術對注射肉毒桿菌A有反應的偏頭痛病患可能有益


  Dec. 30, 2004 - 根據一項發表於1月號整型與重建手術期刊的隨機分派試驗結果表示,手術對注射肉毒桿菌A有反應的偏頭痛病患可能是有好處的。
  
  首席作者,俄亥俄州克里夫蘭Case Western Reserve大學整型手術臨床教授Bahman Guyuron醫師在新聞中表示,偏頭痛對美國商業的經濟影響因為工作時間的縮短、以及工作能力的下降而逐漸攀高;透過確認偏頭痛的誘發區域,以及執行針對標的的手術,明顯地降低或消除偏頭痛及無法工作的時間。
  
  根據4:1分派法則,125位被診斷為偏頭痛患者中的120位,被隨機分派接受治療,而另外25位被隨機分派作為控制組;治療組病患接受肉毒桿菌A的注射,以找出誘發區域。
  
  接受肉毒桿菌A注射後,89位病患在4個星期後偏頭痛改善,而且接受手術去除誘發區域的肌肉,82位病患的偏頭痛發作頻率、時間長短、或是密度,相較於接受治療前,下降了50%;在這82位病患中,31位(35%)的偏頭痛緩解,而51位(57%)在平均後續追蹤396天中改善;在227次接受單一注射位置中,注射位置外的偏頭痛並沒有改善。
  
  在1年的追蹤期中,19位控制組中的3位(15.8%)報告偏頭痛緩解(P<.001),但是沒有消除。
  
  當與治療前數據以及控制組相比時,治療組中所有變項皆顯著改善,包括偏頭痛特定問卷、偏頭痛失能評估指數、以及36問題短篇健康調查。
  
  對治療組來說,偏頭痛照護的平均年度花費(925美金),相較於治療前花費(7,612美金),以及控制組(5,530美金),皆顯著地下降(P<.001);無法工作的平均月數也從治療前的4.41個月,以及控制組的4.4個月,下降到1.2個月(P=.003)。
  
  與肉毒桿菌A注射有關的副作用,包括227次的注射中有27位病患(12%)指出注射位置不適、82位病患中有19位(23%)太陽穴位置凹陷、55位病患中有15位(27%)頸部痠痛、以及9位病患眼瞼下垂(10%)。
  
  手術治療造成12位病患(19.4%)鼻腔暫時性的乾躁、11位病患(17.7%)流鼻水、7位病患(8.8%)劇烈的頭顱搔癢、以及5位病患(6.3%)輕微的掉髮。
  
  Guyuron醫師表示,手術前,我的病人對於無法控制他們的生活,而感到極端挫折;他們想要工作,以及陪伴他們的家人,透過我們手術上的新發現,我們將能夠幫助適當的病患脫離偏頭痛可怕的痛楚,以及幫助他們重新開始生活。

Surgery Might Benefit Patients

By Laurie Barclay, MD
Medscape Medical News

Dec. 30, 2004 — Surgery might be useful to treat patients with migraine that responds to botulinum toxin A injection, according to the results of a randomized trial published in the January issue of Plastic & Reconstructive Surgery.

"The economic impact of migraine headaches on American businesses is staggering due to the loss of employee time and productivity each year," lead author Bahman Guyuron, MD, clinical professor of plastic surgery at Case Western Reserve University in Cleveland, Ohio, says in a news release. "By identifying the trigger areas for migraines and performing targeted surgical procedures, we significantly reduced or eliminated their migraines and the amount of time missed from work."

Based on a 4:1 allocation, 100 of 125 patients diagnosed with migraine headaches were randomized to the treatment group and 25 were randomized to the control group. Patients in the treatment received injections of botulinum toxin A to identify trigger sites.

Of 89 patients who had improvement in their migraines for four weeks with botulinum toxin A injection and underwent surgery to remove the muscle underlying trigger sites, 82 patients had at least a 50% reduction from baseline in migraine headache frequency, duration, or intensity. Of these 82 patients, 31 (35%) had elimination of their headaches, and 51 (57%) had improvement over a mean follow-up period of 396 days. Improvement of migraine headache outside of the injected site was not seen following any of the 227 single-site injections.

During the one-year follow-up, three of 19 control patients (15.8%) reported reduction in migraine headaches (P < .001), and none reported elimination.

When compared with the baseline data and the control group, all variables improved significantly for the treatment group, including the Migraine-Specific Questionnaire, the Migraine Disability Assessment score, and the Short Form-36 Health Survey.

For the treatment group, the mean annualized cost of migraine care was reduced significantly ($925) compared with the baseline expense ($7,612) and the control group ($5,530) (P < .001). The mean monthly number of days lost from work was 1.2 in the treatment group, 4.41 at baseline, and 4.4 in the control group (P = .003).

Common adverse effects related to botulinum toxin A injection were injection site discomfort in 27 patients after 227 injections (12%), temple hollowing in 19 of 82 patients (23%), neck weakness in 15 of 55 patients (27%), and eyelid ptosis in nine patients (10%).

Surgical treatment resulted in temporary dryness of the nose in 12 patients (19.4%), rhinorrhea in 11 (17.7%), intense scalp itching in seven (8.8%), and minor hair loss in five (6.3%).

"Before surgery, my patients expressed extreme frustration by not being able to gain control of their lives," Dr. Guyuron says. "They wanted to work or spend time with their family. Through our new surgical discoveries, we are able to help the appropriate patients escape the awful effects of migraines and start living their lives again."

Plastic & Reconstructive Surgery. 2005; 115:xxx-xxx

Reviewed by Gary D. Vogin, MD

    
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