RU2850623C1 - Method of treating paediatric patients with chronic tension headaches - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to therapy, paediatrics, neurology, physiotherapy, physical and medical rehabilitation, and is intended for the treatment of paediatric patients with chronic headaches. Rhythmic transcranial magnetic stimulation is performed using a non-contact technique that allows selective exposure to specific areas of the cerebral cortex responsible for pain perception, the formation of central sensitisation, and the control of cognitive and mental processes, and activates the mechanisms of intracerebral neuroplasticity. Paediatric patients with chronic tension headaches underwent a course of daily rhythmic transcranial magnetic stimulation procedures. The inductor was placed on the left dorsolateral prefrontal cortex, and the parameters were set on the screen: power 70-90% of the individual threshold value of the evoked motor response depending on age, frequency 10 Hz in intermittent mode, the total duration of the procedure was 16-19 minutes.

EFFECT: reduction in the intensity and frequency of headache episodes, improvement in the prognosis of the disease and quality of life.

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Description

The invention relates to the field of medicine, specifically therapy, pediatrics, neurology, physiotherapy, and physical and medical rehabilitation. It is intended for the treatment of pediatric patients with chronic headaches. The method reduces the intensity and frequency of headache episodes, improves the prognosis of the disease, and improves quality of life.

Chronic pain in children results from the dynamic integration of biological processes, psychological factors, and sociocultural variables, considered within the context of the child's developmental trajectory. The relevance of this study lies in the fact that globally, 20-35% of children and adolescents suffer from chronic pain. In the Russian Federation, the prevalence of chronic pain syndromes in pediatric practice reaches 38.1% among children aged 9 to 17 years. Characteristic types of chronic pain include recurrent abdominal pain, musculoskeletal pain, and headache. A combination of different types of pain syndromes is possible, with prevalence reaching 21%. Headache is the most common type of chronic pain, accounting for 55% of all pain syndromes.

Various studies and literature sources have shown that chronic pain is a risk factor for psychosomatic diseases, reduces the quality of life of the pediatric population, and children with this disease are more likely to take medications than children without it (55% versus 39%).

The work by Izmailova I.G. et al. and Esin O.R. showed that risk factors for chronic pain include depression, anxiety in children and their mothers, low self-esteem, low socioeconomic status, a large number of activities outside of school hours, school stress, a positive family history (“pain families”), sad thoughts in young girls, other chronic health problems, personality traits (demonstrative, hypochondriacal, excitable, dependent personality traits), and alexithymia.

Rhythmic transcranial magnetic stimulation (rTMS) is currently an innovative and promising method of applying a high-intensity pulsed magnetic field to areas of the cerebral cortex associated with the analysis of sensory pain signals, the process of central sensitization, which forms the neurophysiological basis for the formation of chronic pain, as well as areas that control cognitive and mental processes.

The physiological basis of the method is related to the effect of induced electric current, that is, resulting from electromagnetic induction, and the subsequent activation of neurons in the cerebral cortex and the conductive structures of the nervous system. The mechanism of action of rTMS is considered to be the effect of neuromodulation, that is, the ability to alter signal transmission along neural pathways, which manifests itself in the modulation of the pain signal and the ability to influence the flow of sensory information that constitutes the process of central sensitization (Galhardoni R., Correia G.S., H. Araujo. Repetitive Transcranial Magnetic Stimulation in Chronic Pain: A Review of the Literature. Archives of Physical Medicine and Rehabilitation. 2015;96(4):156-172). Also, the analgesic effect of rTMS is mediated by the endogenous opioid system, in particular, by the effect on μ-receptors, as well as by the activation of the periaqueductal gray matter and the NMDA receptors located there (De Andrade D.C., Mhalla A., Adam F. Neuropharmacological basis of rTMS-induced analgesia: the role of endogenous opioids. Pain. 2011;152:320-326).

The use of this therapeutic factor in clinical pediatric practice allows for a significant reduction in the number of analgesic drugs taken and the severity of pain syndrome, resulting in an improvement in the quality of life of patients and social adaptation, including in terms of educational activity.

The described advantages, together with its relative simplicity and non-invasiveness, make repetitive transcranial magnetic stimulation a promising method for the treatment and rehabilitation of pediatric patients with chronic tension-type headache.

In modern medicine, various non-drug methods of treating headache syndromes are currently used.

A known method for treating psychogenic headaches involves applying a rectangular, monopolar, pulsed electric current to the head (symmetrical frontal and mastoid areas) with a pulse duration of 0.3 ms at the threshold of sensation (current amplitude 0-5 mA) at a constantly changing frequency with a resolution of 1 Hz every second in the frequency range of 13-18 Hz. A session consists of three series of exposures, each lasting 4 minutes, with a 1-minute interval between them (RU 2096047C1 IPC A61N1/32). The course of therapy consists of six sessions, one every other day. This reduces the severity of headaches and feelings of internal tension, and improves concentration. This is a relatively simple, painless treatment method.

However, the above-described method has not been confirmed to be effective and safe in children, and does not provide a long-term analgesic effect when implementing the chosen course of therapy.

A method for treating chronic tension headache in children is known (RU 2825525 C1 IPC A61H1/00). During the therapeutic intervention, the authors conducted 12 sessions, during each of which the patients sequentially performed the following exercises: twisting the torso forward on a horizontal bench using the abdominal press 20 times; hyperextension exercise on an inclined bench at an angle of 45° 15 times; exercise raising dumbbells forward in front of you 15 times; raising dumbbells through the sides 15 times; then standing shrugs with dumbbells shoulder raise 15 times, after which a bar press from behind the head, then a cross row while sitting on a bench, 15 times; shrugs exercise with a tilt of the head, then an exercise pulling the upper block to the chest, sitting, with a wide grip, 15 times; This was followed by a pullover while seated in a crossover machine on an incline bench at a 45° angle. Then, head crunches, followed by 15 shoulder rotations, 20 standing squats, standing calf raises, and 20 straight-leg pulldowns from a high block. Afterward, they moved on to an exercise that decompressed the neck vessels, followed by manual manipulation of the occipitovertebral muscles. As a result of this manipulation, the authors observed a reduction in muscle tension and a decrease in the intensity of tension headaches.

The disadvantage of the above-described method is that it only relieves muscle spasms, which does not address the primary pathogenic mechanisms of chronic tension-type headache: central sensitization and decreased activity of the body's antinociceptive system. Furthermore, this method does not provide a prolonged effect or improve the prognosis.

A method for treating chronic daily headache is known (RU 2321387 C1 A61H 39/08 (2006.01) A61M 21/02 (2006.01) A61K 31/5415 (2006.01) A61P 25/06 (2006.01)). This method includes daily pulse and acupuncture diagnostics; taking tranquilizers, antidepressants and neuroleptics, homeopathic drugs with sedative and antispasmodic action; auto-training, rational, hypnosuggestive, family and sexual psychotherapy; Superficial multi-needle acupuncture, transcutaneous electrical nerve stimulation, acupressure and deep massage of the cervical, shoulder, back, lumbosacral, and gluteal regions, alternating every other day with deep abdominal massage and acupressure of the anterior chest wall; and scalp massage. The authors achieve clinical recovery, social adaptation, improved quality of life, and reduced treatment time.

The disadvantages of this method include the possibility of side effects from the medications taken, the duration of prophylactic use of drugs, the relatively low effectiveness of the method, and the impossibility of widespread use of the method in the absence of highly specialized specialists.

The closest analogue adopted for the treatment of tension-type headache is transnasal electrical stimulation of the nasal mucosa in the rhythm of the patient's breathing (RU 2170597 C1 A61N 1/36). The stimulation was administered at the height of inspiration with a current of 10 μA, increasing the current by 3-5 μA every 5 minutes to 20-25 μA for 15-20 minutes daily for a course of 10-12 treatments. The authors suggest that rhythmic transnasal electrical stimulation facilitates the disintegration and reorganization of the pathological system, activating the brain's pain-relieving mechanisms, thereby increasing the effectiveness of treatment.

The disadvantages of the closest analogue should be considered

• electrical stimulation of the nasal mucosa may cause discomfort associated with local irritation

• the effectiveness and safety of the method have not been demonstrated in pediatric patients

• the impact on the afferent endings in the nasal cavity does not allow influencing the cortical mechanisms of the formation of chronic pain syndrome

• electrical stimulation is a contact technique, which can be a limiting factor in patients with respiratory diseases and damage to the integrity of the nasal mucosa

• the described method does not allow activating neurons of the cerebral cortex and influencing the processes of intracerebral connectivity and neuroplasticity.

The objective of the present invention is to create a method for influencing physical factors for the treatment of chronic tension-type headache in children, which would provide a reduction in the intensity of the pain syndrome, a decrease in the duration and frequency of headache episodes, as well as the number of analgesic drugs taken, an improvement in the quality of life and social adaptation, taking into account the correction of concomitant psychoemotional disorders, and would have good tolerability and a favorable safety profile.

The stated problem is solved due to the fact that the method of action differs from the prototype method in that rhythmic transcranial magnetic stimulation is a contactless technique that allows for selective action on individual areas of the cerebral cortex responsible for pain perception, the formation of central sensitization, the control of cognitive and mental processes, and the activation of mechanisms of intracerebral neuroplasticity.

The proposed method involved pediatric patients with chronic (lasting more than 3 months) tension-type headaches undergoing a 10-day course of rhythmic transcranial magnetic stimulation (RTMS) using a Tamas device (manufacturer: REMED Co. LTD., Republic of Korea). The inductor was positioned over the left dorsolateral prefrontal cortex, and the following parameters were set on the screen: a power of 70-90% of the individual evoked motor response threshold (EVRT) depending on age, a frequency of 10 Hz, and an intermittent mode (4 seconds on, 11 seconds off). The total duration of the procedure was 16-19 minutes (a total of 2,500-3,000 pulses).

In this case the following is observed:

1. Reduction in the number of days with headaches, reduction in the intensity and duration of pain.

2. Improvement of mood, quality of life and daily activity.

The technical result is achieved by the authors' proposed method for treating chronic tension-type headaches using rhythmic transcranial magnetic stimulation. This demonstrates that:

• This method has an analgesic effect due to the activation of the antinociceptive system, eliminating the process of central sensitization.

• This method has anti-anxiety, anti-depressant and anti-asthenic effects.

• The procedure can be carried out for a long time, since there is no addiction to this method of exposure.

• This method has the ability to improve intracerebral connectivity and neuroplasticity.

The technical result is a reduction in the number of headache days, a decrease in the intensity and duration of pain, and an improvement in mood, quality of life, and daily functioning. The method has analgesic, anti-anxiety, antidepressant, and anti-asthenic effects, and is non-addictive.

The method is carried out as follows.

Before starting a course of therapy, the physician determines the threshold of the evoked motor response using the classical method, which is expressed as the minimum intensity of the magnetic stimulus (pulse) as a percentage of the intensity of the magnetic inductor, which is required to register a response from the target muscle in 5 out of 10 cases. stimulus delivery (Rossini PM, Barker AT, Berardelli A, Caramia MD, Caruso G, Cracco RQ, Dimitrijević MR, Hallett M, Katayama Y, Lücking CH, et al. Non-invasive electrical and magnetic stimulation of the brain, spinal cord, and roots: basic principles and procedures for routine clinical application. Report of an IFCN committee. Electroencephalogr Clin Neurophysiol. 1994). Before each procedure, the physician conducts a brief survey on therapy tolerability and the presence of adverse effects. The exposure is carried out using repetitive transcranial magnetic stimulation. The procedures are carried out on the area of the left dorsolateral prefrontal cortex with the following parameters: power of 70-90% of the individual value of the evoked motor response threshold depending on age, frequency of 10 Hz in intermittent mode (4 seconds burst, 11 seconds pause), the total duration of the procedure was 16-19 minutes (a total of 2500-3000 pulses).

Objective criteria for assessing the effectiveness of treatment are: a reduction in the number of episodes (days) with headaches, the intensity and duration of pain syndrome, and a reduction in the symptoms of emotional disorder (anxiety and depression).

The possibility of implementing the claimed invention is shown by the following examples.

Description of a clinical case

Example 1. Patient K., 11 years old, came to Children's City Polyclinic No. 39 with complaints of frequent headaches (3-5 days a week/12-17 days a month) of a pressing and squeezing nature in the temporal and frontal regions on both sides, more on the right, intensifying against the background of loud sounds (phonophobia), with an intensity of 5-8 points on a 10-point visual analogue scale, fatigue, periodically appearing "sad thoughts" without a reason.

The patient has been experiencing headaches for 1.5 years. Previously, headaches were rare, but their frequency has increased in the last 6 months. The patient takes analgesics (ibuprofen, acetylsalicylic acid) for pain relief, with a short-term or no effect (in this case, pain relief occurs after a night's sleep). The duration of a painful episode is 4-10 hours. A physical examination revealed no signs of focal damage to the nervous system. The following examinations were performed: magnetic resonance imaging of the brain, electroencephalography, ophthalmologist examination, duplex scanning of the arteries of the head and neck, and electrocardiography. The Spielberger-Hanin scale revealed an average level of situational (reactive) and personal anxiety (35 and 44 points, respectively); the Hospital Depression Scale (HADS) showed a score of 3 points (absence of depressive symptoms). Following further examination, a diagnosis was made: Chronic tension headache. Anxiety disorder.

The patient underwent rhythmic transcranial magnetic stimulation with an intensity of 70% of the individual's evoked motor response threshold (corresponding to 30% of the device's output power), a frequency of 10 Hz, and intermittent delivery (4-second burst, 11-second pause). The total treatment duration was 16-19 minutes (the first session lasted 16 minutes, then 19 minutes). The treatment course consisted of 10 daily sessions.

After 5 procedures, the patient showed positive dynamics, including a decrease in pain intensity to 4 points, and two headache episodes lasting up to 60 minutes. After completing a course of 10 procedures, the patient noted a decrease in the frequency of pain (during the course of therapy, headaches bothered her twice), and pain intensity to 1-2 points, which subsided spontaneously within 60 minutes and did not require medication. The patient also noted an improvement in her general condition, increased activity, and interest in schoolwork. The following scales were assessed: Spielberger-Hanin Statement Anxiety Scale - 23 points (low level), Personal Anxiety - 32 points (moderate); Hospital Depression Scale HADS-4 points (absence of depressive symptoms). The patient tolerated the procedures satisfactorily, no adjustment of stimulation parameters was required, and no adverse events were recorded.

When assessing the long-term treatment effect after one month, five days of headache symptoms with an intensity of 1-2 points were recorded, which resolved spontaneously within one to two hours. The patient maintains a favorable emotional state and motivation for school.

Example 2. Patient B., 14 years old, came to Children's City Polyclinic No. 39 with complaints of frequent headaches (5 days a week) of a squeezing, aching nature, bilateral localization mainly in the frontal region, with an intensity of 6-7 points on a 10-point visual analogue scale, fatigue, decreased mood, emotional lability.

The patient has been experiencing pain for 6 months, most often during periods of stress at school. He takes analgesics (ibuprofen, acetylsalicylic acid) for pain relief. Their effect is short-lived (pain returns the next day). The average duration of a painful episode is 7.5 hours. Examination revealed no somatic pathology, and the patient's neurological status is normal, with no local tenderness or symptoms of muscular-tonic syndrome. Additional examinations included magnetic resonance imaging of the brain, electroencephalography, and an ophthalmological examination (visual acuity, fundus examination). No pathological abnormalities were revealed. The Spielberger-Hanin Anxiety Scale revealed a moderate level of situational (reactive) and personal anxiety (43 and 44 points, respectively); the Hospital Depression Scale (HADS-9) revealed a score of 9 (subclinical depression). Following further examination, a diagnosis was made: Chronic tension-type headache. Anxiety-depressive disorder.

The patient underwent rhythmic transcranial magnetic stimulation with an intensity of 90% of the individual's evoked motor response threshold (corresponding to 37% of the device's output power) and a frequency of 10 Hz in intermittent mode (4-second burst, 11-second pause). The total duration of the procedure was 16-19 minutes (the first procedure lasted 16 minutes, then 19 minutes). The treatment course consisted of 10 daily sessions.

After 5 procedures, the patient demonstrated positive dynamics, including a decrease in pain intensity to 4-5 points, and a single headache episode. After completing a course of 10 procedures, the patient noted a decrease in the frequency of pain (headaches occurred twice during the course of therapy), and pain intensity down to 2-3 points, which subsided spontaneously within 2 hours and did not require medication. The patient also noted an improvement in mood and stabilization of his emotional state. The following scales were assessed: Spielberger-Hanin anxiety scale: situational (reactive) anxiety 18 points (low level), personal anxiety 32 points (moderate); Hospital Depression Scale HADS-6 points (absence of depressive symptoms). The patient tolerated the procedures satisfactorily; no adjustment of stimulation parameters was required, and no adverse events were recorded.

When assessing the long-term treatment effect after one month, four days of headache symptoms with an intensity of 2-3 points were recorded during this period. These headaches resolved spontaneously within 3-4 hours and after sleep. The patient's emotional state remains stable.

From September 2022 to March 2025, 92 patients were treated using the proposed method at Children's City Polyclinic No. 39.

The technical result is a reduction in the number of headache days, a decrease in the intensity and duration of pain, and an improvement in mood, quality of life, and daily functioning. The method has analgesic, anti-anxiety, antidepressant, and anti-asthenic effects, and is non-addictive.

Claims (1)

A method for treating pediatric patients with chronic tension headaches, including the implementation of rhythmic transcranial magnetic stimulation, characterized in that 10 procedures are carried out daily, lasting 16-19 minutes of exposure to rhythmic transcranial magnetic stimulation from the Tamas device, the inductor is placed on the surface of the skull in the projection of the left dorsolateral prefrontal cortex and the parameters are set: power of 70-90% of the individual value of the threshold of the evoked motor response, frequency of 10 Hz in intermittent mode: 4 seconds burst, 11 seconds pause.