偏頭痛與貝爾氏麻痺有關


  【24drs.com】研究者指出,偏頭痛患者發生貝爾氏麻痺的風險,是無偏頭痛者的近2倍。
  
  這篇觀察型研究的對象包括偏頭痛患者組與對照組,研究發現偏頭痛與貝爾氏麻痺有關;貝爾氏麻痺是一種急性、患側面部神經癱瘓的疾病,會導致頸闊肌及顏面表情肌肉虛弱,與性別或偏頭痛類型無關。
  
  研究作者、台灣國立陽明大學醫學院、台北榮民總醫院神經研究中心副主任王署君醫師表示,研究結果指出,醫師應詢問病患有無偏頭痛。
  
  王醫師表示,在臨床實務,除了高血壓、糖尿病、懷孕,貝爾氏麻痺患者還必須追蹤偏頭痛病史。他強調,這對於年輕患者特別重要,因為他們通常不會有高血壓或糖尿病。
  
  他們的研究結果線上發表於12月17日的神經學期刊。
  
  研究者使用台灣健保研究資料庫(NHIRD)的數據,彙整兩組18歲以上的研究對象:(1)全部都是在2005年1月至2009年12月診斷有偏頭痛(先兆偏頭痛、無先兆偏頭痛、不明原因偏頭痛)的病患,(2)從NHIRD隨機取樣,無偏頭痛或其他頭痛病史的對照組。
  
  原本就有貝爾氏麻痺者、30天內有偏頭痛以及貝爾氏麻痺診斷者不納入研究。
  
  為了盡量減少偏頭痛患者與無偏頭痛對照組之間的既有差異,研究者使用傾向得分配對;對偏頭痛組的每個病患,研究者找一個人口統計學特徵相仿的對照組,年齡與偏頭痛診斷可能性之傾向得分相當。
  
  傾向得分配對分析,在偏頭痛組與對照組各包括了136,704名研究對象。平均追蹤3.2年之後,偏頭痛組有671人、對照組有365人新診斷有貝爾氏麻痺,每100,000病患-年之發生率分別是158.1、83.2。
  
  對照組的貝爾氏麻痺發生率高於之前的報告數據(每100,000病患-年為13.1-53.3)。王醫師表示,這個差異可能是因為台灣健保的整體涵蓋率高以及數據完整。
  
  偏頭痛是相當常見的,全球年度盛行率約為10%,女性患者多於男性,這篇研究中,貝爾氏麻痺的男女比率,在偏頭痛組為1.4:1,在對照組為1.1:1。
  
  偏頭痛患者的貝爾氏麻痺風險比較高(風險比1.91;95%信心區間1.68 - 2.17;P < .001)。不論有傾向得分配對以及沒有傾向得分配對,偏頭痛與貝爾氏麻痺的關聯性相似。
  
  若採用不同的貝爾氏麻痺診斷準則,關聯性依舊顯著,在依照性別、年齡、Charlson共病症指數分數、糖尿病、高血壓、偏頭痛類型分組的各組分析結果也一致。
  
  王醫師表示,我們並未發現先兆型和無先兆偏頭痛之間(與貝爾氏麻痺之關聯)有差異,這與之前的血管共病症研究不同,該研究顯示先兆偏頭痛與中風或心肌梗塞有關,而無先兆偏頭痛則是無關。
  
  王醫師表示,越常因為偏頭痛就診的患者越可能發生貝爾氏麻痺,我們假設,偏頭痛發作越頻繁或越嚴重,易使顏面神經受損而發生貝爾氏麻痺。
  
  王醫師表示,儘管他與研究同僚已經報告指出,偏頭痛患者發生與第八對腦神經、或耳蝸神經有關之突發性耳聾的機率較高,他對研究結果仍有點驚訝,所以我們認為,我們可能可以有機會證明偏頭痛和貝爾氏麻痺的關聯。
  
  根據王醫師指出,有許多機轉可以解釋偏頭痛和貝爾氏麻痺之關聯,但是,最好的假設是顱神經附近的神經源性發炎可能會誘發顏面神經脫髓鞘,這或許是在病毒感染之後發生。此次研究排除在30天內有帶狀皰疹病毒感染的病患,但是研究者並未評估病患的檢驗數據。
  
  他表示,還無足夠證據排除或納入神經源性感染這項因素。關鍵可能是偏頭痛與貝爾氏麻痺的共同機轉。不過,大多數研究顯示,先兆偏頭痛與血管共病症有關,無先兆偏頭痛則否。
  
  這次的研究,先兆型與無先兆偏頭痛之間並無差異,顯示「神經源性發炎這項假設」是合理的。
  
  研究限制是,貝爾氏麻痺主要是臨床診斷,資料庫中的臨床資訊有限,所以有一些案例可能是其他原因造成的顏面肌肉無力。同時,偏頭痛患者這組都有活性偏頭痛,可能無法代表非活性偏頭痛者。
  
  賓州費城Thomas Jefferson大學Stephen Silberstein醫師,以及義大利Ancona Marche理工大學Mauro Silvestrini醫師在編輯評論寫道,這些研究結果有幾個意義,除了提出偏頭痛是貝爾氏麻痺的因素之一,作者們還發表了與這兩個疾病有關的一些假設。
  
  可能是發炎、感染以及血管方面的變化,使偏頭痛與貝爾氏麻痺之間有所關聯,這值得進一步探討,以獲得有關更新之治療策略的見解。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=7144&x_classno=0&x_chkdelpoint=Y
  

Migraine Linked to Risk for Bell's Palsy

By Pauline Anderson
Medscape Medical News

Patients with migraine have almost double the risk of developing Bell's palsy compared with those without migraine, researchers report.

Their observational cohort study of patients with migraine and matched controls found that the association between migraine and Bell's palsy, an acute, ipsilateral facial nerve paralysis that results in weakness of the platysma and muscles of facial expression, was not affected by sex or migraine subtype.

The results suggest that physicians should ask patients about migraine, study author Shuu-Jiun Wang, MD, deputy director, Neurological Institute, Taipei Veterans General Hospital, and chairman, Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, told Medscape Medical News.

"In clinical practice, in addition to hypertension, diabetes, and pregnancy, migraine history should be traced in patients with Bell's palsy," said Dr Wang. He stressed that this is especially important in young people, who usually don't have hypertension or diabetes.

Their findings were published online December 17 in Neurology.

Researchers used data from the Taiwan National Health Insurance Research Database (NHIRD) to assemble two cohorts aged 18 years and older: (1) all patients diagnosed with migraine (migraine with aura, migraine without aura, and migraine unspecified) from January 2005 to December 2009 and (2) matched controls without migraine or other headache extracted from a random sample in NHIRD.

Participants with Bell's palsy at baseline were excluded from the study, as were those in whom migraine and Bell's palsy were both diagnosed within 30 days.

To minimize baseline differences between the patients with migraine and participants without migraines, researchers used propensity score matching. For each patient in the migraine cohort, they identified one control participant with similar demographic characteristics, matched in terms of age and propensity score for the likelihood of a migraine diagnosis.

The propensity score–matched analysis included 136,704 participants in each of the migraine and control cohorts.

After a mean follow-up of 3.2 years, 671 persons in the migraine group and 365 in the control group were newly diagnosed with Bell's palsy. The incident rates were 158.1 and 83.2 per 100,000 patient-years, respectively.

This incidence of Bell's palsy in the control group was higher than previously reported (13.1 to 53.3 per 100,000 person-years). This discrepancy, said Dr Wang, might be explained by the accessibility and global coverage of Taiwan's National Health Insurance plan.

Migraine is quite common, with an annual global prevalence of about 10%. It affects more females than males. The male-to-female ratios of Bell's palsy in this study were 1.4 to 1 in the migraine cohort and 1.1 to 1 in the control cohort.

Patients with migraine had greater risk for Bell's palsy (hazard ratio, 1.91; 95% confidence interval, 1.68 - 2.17; P < .001). The association between migraine and Bell's palsy was similar with and without propensity score matching.

The association remained significant with use of different diagnostic criteria for Bell's palsy, and it was consistent in subgroups defined according to sex, age, Charlson Comorbidity Index score, diabetes, hypertension, and migraine subtype.

"We did not find a difference between migraine with aura and without aura," commented Dr Wang. "This is in contrast to prior studies on vascular comorbidities," which showed that migraine with aura but not migraine without aura is associated with stroke or myocardial infarction.

Migraineurs with more clinic visits for migraine were more likely to develop Bell's palsy, said Dr Wang. "We hypothesize that more frequent or severe migraine attacks might predispose facial nerves to subsequent Bell's palsy."

Dr Wang said he was somewhat surprised by the study results, although he and his colleagues had already reported that patients with migraine have a higher chance of developing sudden sensorineural hearing loss related to the eighth cranial nerve, or the cochlear nerve. "So we thought that we might have a chance to demonstrate the association between migraine and Bell palsy."

Hypothesis

Several mechanisms may explain the link between migraine and Bell's palsy, but the "top hypothesis," according to Dr Wang, is that neurogenic inflammation of nearby cranial nerves may predispose the facial nerve to demyelination, perhaps after a viral infection. Dr Wang noted that the study excluded patients with concomitant herpes zoster infection within 30 days but that researchers had no access to patient laboratory data.

"It's premature to either rule in or rule out the role of neurogenic infection," he said.

A shared mechanism between migraine and Bell's palsy might be at play. "However, most studies show migraine with aura, but not migraine without aura, is linked to vascular comorbidities," noted Dr Wang. The lack of differential effects between migraine with and without aura in the current study "renders this hypothesis behind neurogenic inflammation" in terms of plausibility, he said.

A limitation of the study was that Bell's palsy is primarily a clinical diagnosis and the database has limited clinical information, so some cases may have been due to another cause of facial weakness. As well, the migraine cohort had active migraine, possibly leading to the under-representation of people with nonactive migraine.

The study results have several implications, Stephen Silberstein, MD, Thomas Jefferson University, Philadelphia, Pennsylvania, and Mauro Silvestrini, MD, Marche Polytechnic University, Ancona, Italy, write in an accompanying editorial.

"Besides suggesting a role for migraine as a risk factor for Bell palsy, the authors raise a number of hypotheses about the presence of common mechanisms underlying both diseases," they write.

"The possibility that inflammation, infection, and vascular changes may be implicated in sustaining the association between migraine and Bell palsy is worthy of further investigation to obtain insight about new therapeutic strategies."

The study was supported by the National Science Council of Taiwan, the Taipei Veterans General Hospital, National Yang-Ming University, and the Taiwan Ministry of Education. Dr Wang has served on the advisory boards of Allergen and Eli Lilly Taiwan. He has received speaking honoraria from local companies (Taiwan branches) of Pfizer, Eli Lilly, and GSK. He has received research grants from the Taiwan National Science Council, Taipei Veterans General Hospital and Taiwan Headache Society. Dr Silberstein serves as a consultant and/or advisory board member and receives honoraria from Alder Biopharmaceuticals, Allergan Inc, Amgen, Avanir Pharmaceuticals Inc, eNeura Inc, ElectroCore Medical LLC, Medscape LLC, Medtronic Inc, Mitsubishi Tanabe Pharma America Inc, National Institutes of Neurological Disorders and Stroke, Pfizer Inc, Supernus Pharmaceuticals Inc, and Teva Pharmaceuticals. Dr Silvestrini has disclosed no relevant financial relationships.

Neurology. Published online December 17, 2014.

    
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