新研究:前额拉皮可以缓解偏头痛


  August 28, 2009 — 根据8月份整形与重建外科(Plastic and Reconstructive Surgery)期刊的一篇安慰剂控制外科试验结果,对于难以用标准方式控制的偏头痛病患,或许有一个可以有疗效且兼具美观的新选择。
  
  俄亥俄州克里夫兰凯斯西储大学的Bahman Guyuron医师等人报告指出,强度、频率与疼痛期间均减少至少50%。如果将诱发部位以手术去活化,反应率可跃升到90%。
  
  这些数据已经使不少神经科专家感到困惑。Guyuron医师向Medscape Neurology表示,好得令人难以置信?他已经听到诸多疑问。他表示,某种程度的怀疑是可接受的,但是,在我的心目中,我们的结果是无庸置疑的,病患的确出现肯定的正向反应。
  
  达拉斯德州大学西南医学中心Jeffrey Janis医师表示同意。我完全了解那些顾虑;这曾经被视为一种实验方法。这当然不是照护标准,但是可以作为对传统疗法反应不佳之病患的替代方法。
  
  【实验方法】
  在该期刊的编辑评论中,Janis医师指出,简而言之,这篇文献显示出一个明确的证据,对于治疗偏头痛来说,使用外科方法让外围的诱发点减压,是一个有效的观念。
  
  在这篇双盲、伪手术、控制临床试验中,研究者探讨75名中度到严重偏头痛病患。研究者确认偏头痛诱发位置:额头、太阳穴、枕骨,之后将病患随机分组。
  
  相较于控制组,前额拉皮组在1年时的各项偏头痛效果确认检查均有显著改善。这些改善与诱发部位无关。
  
  【1年时减少的偏头痛】

结果

前额拉皮 (%)

伪手术 (%)

P

减少 50% 的偏头痛

83.7

57.7

<.05

手术后没有偏头痛

57.1

3.8

<.001


  研究者在一个不住院手术中心进行所有手术,且平均手术时间不到1小时。病患可在1周内恢复日常活动,3周恢复重度运动。
  
  最常见的手术并发症是太阳穴偏头痛组的太阳穴略为凹陷。
  
  【副作用】

事件

组别

百分比

1 年时感到麻木

太阳穴

5

凹陷

太阳穴

53

相当痒

额头

11

眉头动作不对称

额头

5

太阳穴毛发掉落或变少

太阳穴

5

残余的皱眉肌功能

额头

5

1 年时脖子僵硬

枕骨

9


  Guyuron医师与其团队提出一个解释手术利益的可能机转。他们认为,与三叉神经的外围活化以及后续的外围和中央敏感化有关。
  
  虽然结果显示某种程度的效果,研究中依旧有些问题。例如,接受伪手术的26名病患中,有1人在1年时也是偏头痛消失。
  
  研究者认为,这可能是手术破坏了表皮、神经操作时的麻痹、或者是安慰剂效应。不过,效果的确持续到1年时。
  
  其它49名接受前额拉皮的病患中,有8人的偏头痛在治疗后没有改变。作者们指出,只有描述1个诱发点,这可能忽略了其它可能的偏头痛。Janis医师表示,他不担心这些数据。事实是,在这主题的所有临床研究中,依旧有少数没有反应的人。
  
  Guyuron医师表示,他的团队将在10月发表新的5年的结果。他表示,是有效果的。
  
  偏头痛基金会、整形外科教育基金、Prentiss基金会资助本研究。共同作者、凯斯西储大学的Deborah Reed医师报告指出,她担任Allergan和GlaxoSmithKline药厂的顾问。共同作者、凯斯西储大学的Jennifer Kriegle医师报告指出,她担任Pfizer、GlaxoSmithKline、Merck和Endo药厂的顾问。
  
  

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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