新研究:前額拉皮可以緩解偏頭痛


  August 28, 2009 — 根據8月份整形與重建外科(Plastic and Reconstructive Surgery)期刊的一篇安慰劑控制外科試驗結果,對於難以用標準方式控制的偏頭痛病患,或許有一個可以有療效且兼具美觀的新選擇。
  
  俄亥俄州克里夫蘭凱斯西儲大學的Bahman Guyuron醫師等人報告指出,強度、頻率與疼痛期間均減少至少50%。如果將誘發部位以手術去活化,反應率可躍升到90%。
  
  這些數據已經使不少神經科專家感到困惑。Guyuron醫師向Medscape Neurology表示,好得令人難以置信?他已經聽到諸多疑問。他表示,某種程度的懷疑是可接受的,但是,在我的心目中,我們的結果是無庸置疑的,病患的確出現肯定的正向反應。
  
  達拉斯德州大學西南醫學中心Jeffrey Janis醫師表示同意。我完全瞭解那些顧慮;這曾經被視為一種實驗方法。這當然不是照護標準,但是可以作為對傳統療法反應不佳之病患的替代方法。
  
  【實驗方法】
  在該期刊的編輯評論中,Janis醫師指出,簡而言之,這篇文獻顯示出一個明確的證據,對於治療偏頭痛來說,使用外科方法讓週邊的誘發點減壓,是一個有效的觀念。
  
  在這篇雙盲、偽手術、控制臨床試驗中,研究者探討75名中度到嚴重偏頭痛病患。研究者確認偏頭痛誘發位置:額頭、太陽穴、枕骨,之後將病患隨機分組。
  
  相較於控制組,前額拉皮組在1年時的各項偏頭痛效果確認檢查均有顯著改善。這些改善與誘發部位無關。
  
  【1年時減少的偏頭痛】

結果

前額拉皮 (%)

偽手術 (%)

P

減少 50% 的偏頭痛

83.7

57.7

<.05

手術後沒有偏頭痛

57.1

3.8

<.001


  研究者在一個不住院手術中心進行所有手術,且平均手術時間不到1小時。病患可在1週內恢復日常活動,3週恢復重度運動。
  
  最常見的手術併發症是太陽穴偏頭痛組的太陽穴略為凹陷。
  
  【副作用】

事件

組別

百分比

1 年時感到麻木

太陽穴

5

凹陷

太陽穴

53

相當癢

額頭

11

眉頭動作不對稱

額頭

5

太陽穴毛髮掉落或變少

太陽穴

5

殘餘的皺眉肌功能

額頭

5

1 年時脖子僵硬

枕骨

9


  Guyuron醫師與其團隊提出一個解釋手術利益的可能機轉。他們認為,與三叉神經的週邊活化以及後續的週邊和中央敏感化有關。
  
  雖然結果顯示某種程度的效果,研究中依舊有些問題。例如,接受偽手術的26名病患中,有1人在1年時也是偏頭痛消失。
  
  研究者認為,這可能是手術破壞了表皮、神經操作時的麻痺、或者是安慰劑效應。不過,效果的確持續到1年時。
  
  其他49名接受前額拉皮的病患中,有8人的偏頭痛在治療後沒有改變。作者們指出,只有描述1個誘發點,這可能忽略了其他可能的偏頭痛。Janis醫師表示,他不擔心這些數據。事實是,在這主題的所有臨床研究中,依舊有少數沒有反應的人。
  
  Guyuron醫師表示,他的團隊將在10月發表新的5年的結果。他表示,是有效果的。
  
  偏頭痛基金會、整形外科教育基金、Prentiss基金會資助本研究。共同作者、凱斯西儲大學的Deborah Reed醫師報告指出,她擔任Allergan和GlaxoSmithKline藥廠的顧問。共同作者、凱斯西儲大學的Jennifer Kriegle醫師報告指出,她擔任Pfizer、GlaxoSmithKline、Merck和Endo藥廠的顧問。
  
  

Forehead Lift Eases Migraine Pain, Says New Study

By Allison Gandey
Medscape Medical News

August 28, 2009 — For patients with migraines who are difficult to manage with standard protocols, there might be a new option that could prove to have a therapeutic, as well as a cosmetic, effect. Results from a placebo-controlled surgical trial appear in the August issue of Plastic and Reconstructive Surgery.

Investigators, led by Bahman Guyuron, MD, from Case Western Reserve University in Cleveland, Ohio, report response rates of at least a 50% reduction in intensity, frequency, and duration of migraines. Response rates reportedly jump to as much as 90% when trigger sites are surgically deactivated.

The numbers, though compelling, have furrowed the brow of more than one neurologist. "Too good to be true?" Dr. Guyuron told Medscape Neurology he has heard many variations of this question. "A certain degree of skepticism is healthy," he said, "but there's no question in my mind we are seeing results, and patients are experiencing an enduring positive response."

Jeffrey Janis, MD, from the University of Texas Southwestern Medical Center in Dallas, said he agrees. "I completely understand the concerns; this has been considered an experimental approach. This is certainly not the standard of care, but it may be an alternative for patients experiencing difficulty with traditional therapies."

Experimental Approach

In an accompanying discussion in the journal, Dr. Janis noted that "this article, simply put, represents the definitive proof that surgical decompression of peripheral trigger points in the treatment of migraine headaches is a valid concept."

In this double-blind, sham surgery, controlled clinical trial, investigators studied 75 patients with moderate to severe migraine. Researchers identified migraine trigger sites — frontal, temporal, and occipital — and then randomly assigned patients.

Compared with the control group, the forehead-lift group demonstrated statistically significant improvements in all validated migraine headache measurements at 1 year. These improvements were not dependent on trigger site.

Reductions in Migraine at 1 Year
Outcome Forehead Lift (%) Sham Surgery (%) P Value
50% reduction in migraines 83.7 57.7 <.05
No migraines after surgery 57.1 3.8 <.001

?

Investigators performed all procedures in an ambulatory center with an average surgery time of less than 1 hour. Patients were permitted to resume ordinary activities in 1 week and heavy exercise in 3 weeks.

The most common surgical complication was a slight hollowing of the temple in the group with temporal migraine.

Adverse Events
Events Group Percentage
Numbness at 1 year Temporal 5
Hollowing Temporal 53
Intense itching Frontal 11
Uneven brow movement Frontal 5
Temporary hair loss or thinning Temporal 5
Residual corrugator supercilii muscle function Frontal 5
Neck stiffness at 1 year Occipital 9

Dr. Guyuron and his team propose a possible mechanism to explain the benefit of surgery. They suggest that peripheral activation of the trigeminal nerve with subsequent peripheral and central sensitization could be at play.

Although the results appear promising on some levels, there were problems with the study. For example, 1 of the 26 patients undergoing sham surgery actually had complete elimination of migraines at 1 year.

Researchers suggest this may be attributed to the surgical undermining of flaps, neurapraxias from nerve manipulation, or the placebo effect. But the beneficial effect did persist at 1 year.

Another 8 of the 49 patients who underwent the forehead lift had no change in migraines after treatment. The authors point out that only 1 trigger point was addressed, and this could have neglected others prompting migraine.

Dr. Janis says he's not concerned about these numbers. "The fact is that there exists a small subpopulation of nonresponders in all available clinical studies on this subject."

Dr. Guyuron said his group will present new 5-year results in October. He said the findings are promising.

This study was paid for by the Migraine Foundation, the Plastic Surgery Education Fund, and the Prentiss Foundation. Coauthor Dr. Deborah Reed, from Case Western Reserve University in Cleveland, Ohio, reports that she is a consultant for Allergan and GlaxoSmithKline. Coauthor Dr. Jennifer Kriegler, also from Case Western Reserve University, reports that she is a consultant for Pfizer, GlaxoSmithKline, Merck, and Endo.

Plast Reconstr Surg. 2009;124:461-468.

    
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