神经电刺激治疗慢性头面部疼痛：综述（十九）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

本次文献选自Antony AB,  Mazzola AJ,  Dhaliwal GS, et al. Neurostimulation for the Treatment of Chronic Head and Facial Pain: A Literature Review[J]. Pain Physician, 2019, 22(5):447-477. 本次学习由陈阳住院医师主讲。

Vagal Nerve Stimulation

Vagal nerve stimulation (VNS) has shown efficacy in various conditions with success first illustrated in epilepsy and depression. VNS affects the parasympathetic nervous system and can result in changes in blood brain flow. Although the exact mechanism is not defined, patients with epilepsy treated with VNS were noted to simultaneously have improvements in their headaches. A retrospective case series looked at 34 patients who had been treated with prior VNS, and 10 patients were identified with a prior history of migraines. A total of 8 out of 10 of these patients with migraine reported a reduction of monthly frequency by at least 50% in the first 3 months poststimulator surgical implantation. Although the frequencies of reported migraines were small leading to large percent changes and there is potential for retrospective recall bias, this study highlighted the need for further investigation. A series of 6 cases concluded that 2 out of 2 chronic CH patients had good results with VNS, and 2 out of 4 patients with CM reported excellent relief, whereas the other 2 had poor efficacy. Another case series selected 4 patients suffering from drug-refractory CM with depression for trial with implanted VNS set to 30 Hz. The authors concluded that 2 of the 4 patients improved for both headache and depression at 1 to 3 months postimplant. Clinical trials are recommended to better determine efficacy.

迷走神经刺激

迷走神经刺激（VNS）在各种情况下均显示出疗效，其成功首先体现在癫痫和抑郁症中。VNS影响副交感神经系统，并可能导致脑血流量改变。尽管尚不清楚确切的机制，但已注意到接受VNS治疗的癫痫患者的头痛同时得到改善。回顾性病例系列研究了34例先前接受过VNS治疗的患者，其中10例具有偏头痛的既往病史。在这些偏头痛患者中，10例中就有8例在刺激器手术植入后的前3个月，每月头痛出现的频率降低了至少50％。该文献中偏头痛的发生频率小导致百分比变化大，并且可能存在回顾分析的偏倚，但本研究提示有必要进一步研究。一项收集了6例病人的病例系列发现，2例慢性CH患者的VNS效果良好，4例CM患者中2例的缓解效果良好，而其他2例疗效差。另一个病例系列选择了4例患有药物难治性CM并伴有抑郁症的患者，将其植入的VNS设置为30 Hz进行试验。作者得出的结论是，4名患者中有2名在植入后1到3个月的头痛和抑郁症状均有改善。建议进行临床试验以更好地确定疗效。

Several studies have focused on noninvasive or transcutaneous vagal nerve stimulation (tVNS). In 2016, Silberstein et al reported on their use of tVNS to treat patients with either episodic (67%) or chronic (33%) CH. On initial feelings of attack, patients were instructed to manually deliver 3 consecutive 2-minute stimulations to the right side of the neck. Response was then assessed at 15 minutes. This randomized, double-blind, sham-controlled study with 60 patients in treatment group and 73 in sham group displayed in the cohort previously diagnosed with episodic CH there was a positive response rate, defined as the percent of patients with a pain score of 0 or 1 on a 5-point scale. However, in the total population no significant difference between sham and treatment groups was established. This suggests that tVNS may best treat those with episodic CH. Similarly, in 2016 Silberstein et al studied noninvasive tVNS and this time in chronic migraineurs. In this randomized, sham-controlled trial, the treatment group (n = 30) and sham group (n = 29) did not statistically differ after 2 months. Following this, 27 patients were followed through to 6 months with open-label treatment. At month 8, for the 15 patients who completed treatment the decrease from baseline in headache days was 7.9 and reached statistical significance. At 6 months 38.5% and at 8 months 46.7% of patients achieved > 50% response. Although there was a high loss to follow-up with increasing time that may lead to overrepresentation among responders or regression to the mean, this study suggests that longterm use may be necessary before migraine prophylaxis response is achieved. Gaul et al analyzed 48 patients with chronic CH treated with tVNS with a control of 49 treated with standard of care. Those treated with tVNS had a statistically significant reduction in number of attacks per week with a mean of 3.9 fewer attacks than the control group. This study further suggests the efficacy of tVNS for CH. A case series examined 6 patients with PH that were treated with tVNS with regimens ranging from 2 to 4 doses given either 2 times a day or 3 times a day. A total of 4 of the 6 reported benefits in either frequency or severity from this treatment ranging from 3 months to 5 years.

研究集中在无创或经皮迷走神经刺激（tVNS）。 2016年，Silberstein等人报告了他们使用tVNS治疗偶发性（67％）或慢性（33％）CH的患者。发作启动时，患者被指示手动3次连续2分钟刺激右侧颈部。15分钟后评估效果。这项随机、双盲、假手术对照研究收集了既往诊断为发作性CH的病人，其中治疗组60例，假手术组73例。阳性率，定义为5分制疼痛评分中评为为0或1的患者所占的百分比。但是，总体看，假手术组和治疗组之间没有显着差异。这表明tVNS可能最好用于治疗合并阵发性CH的病人。同样，2016年Silberstein等人研究了非侵入性tVNS，这次是针对慢性偏头痛患者。在该随机对照试验中，治疗组（n = 30）和假手术组（n = 29）在2个月后无统计学差异。此后，对27例患者进行了持续6个月的开放标签治疗。在第8个月，完成治疗的15位患者的发作天数较基线下降7.9，达到统计学意义。在6个月时38.5％和8个月时46.7％的患者获得了> 50％的缓解率。尽管时间越长失访越多，可能导致有效患者的代表性过高或均值下降，但这项研究表明，在偏头痛预防成功之前，长期使用该方法是必要的。Gaul等分析了48例接受tVNS治疗的慢性CH患者，对照组49例接受了标准治疗。接受tVNS治疗的患者每周的发作次数在统计上有显著减少，平均发作次数比对照组少3.9。这项研究进一步表明tVNS对CH的疗效。一个病例系列收集了6例接受tVNS治疗的PH患者，治疗方案为每天2次或每天3次，剂量为2-4治疗量。在6个疗程中，总共报告了4个疗程从3个月到5年不等的频率或严重性。