#406 ‒ 偏头痛、丛集性头痛和紧张性头痛：症状、病因、预防与治疗 | Brian Grosberg, M.D.

这些人深受其害，身体非常虚弱。

These people are thoroughly debilitated.

他们有一半的时间都在忍受头痛。

Half their time is in a state of headache.

没错。

Correct.

好的。

Okay.

所以，有百分之十的人群，他们有一半以上的时间都在受头痛困扰。

So ten percent of the population is experiencing up to fifty percent of

他们的时间都花在头痛上。

their time in headache.

有一到百分之二的人口患有慢性偏头痛，也就是他们——

One to two percent of the population experiences chronic migraine where they have-

超过一半的时间都在头痛。

More than fifty percent.

超过一半的时间都在头痛。

More than fifty percent of the time experiencing headaches.

所以绝大多数人经历的是发作性偏头痛，但发作性偏头痛也有一个范围，对吧？

So the vast majority of people experience episodic migraine, but that episodic migraine is a range, right?

可能一年几次，也可能

It could be a couple times a year to

高达50%的

Up to 50% of

时间。

the month.

高达每月50%的时间。

Up to 50% of the month.

对。

Yeah.

好的。

Okay.

在我们开始聊治疗和其他事情之前，我想说，其实我们现在也可以聊这些。

Before we get into treatments and other things I want to talk about well, we could talk about them now.

跟我讲讲遗传易感性吧。

Tell me a little bit about genetic susceptibility.

显然遗传因素很重要，因为女性患偏头痛的几率是男性的三倍。

Obviously genetics matter given the fact that women are three times more likely than men.

这总是让人首先想到，是不是跟激素有关？

That always makes the first thing one might think as well, is it hormonal?

它跟雌激素、孕激素有多大关系？

How much does it relate to estrogen, progesterone?

我们知道大脑里有这些激素的受体。

We know that there are receptors for these things in the brain.

这种头痛的频率，在育龄期是不是更高？

Does the frequency of this type of headache, is it higher during the reproductive years?

在更年期是不是更高？

Is it higher during the menopausal years?

那就能给我们一些关于激素作用的线索。

That would give us a clue as to the role of hormones.

然后，如果在生育年龄期间，是不是在周期的某个阶段更容易发作？

And then if during the reproductive years, is it higher during any part of the cycle?

你一下子问了好多问题。

That's a lot of information packed.

我来慢慢梳理一下。

I will try to tease that apart.

所以归根结底，是的，激素确实有影响。

And so ultimately, yes, hormones plays a role.

对，遗传也有影响，但偏头痛是多因素的，就是说遗传和环境因素都会影响偏头痛的发生。

Yes, genetics plays a role, but migraine is multifactorial in the sense that genetic environmental factors play a role in experiencing migraine.

所以如果一个人有偏头痛的家族史，那他们自己更容易得偏头痛。

So if somebody has a family history of migraine, they're more likely to end up experiencing migraine.

而且在整个女性的生殖周期和各个激素变化阶段，偏头痛确实在青春期、月经期、怀孕期、哺乳期、围绝经期和绝经期这些时期更容易发作。

And through a woman's reproductive cycle and across hormonal milestones, migraine can certainly have predilection around times of puberty, around times of menses, pregnancy, lactation, perimenopause, and menopause.

所以，在这些激素变化的关键时期，偏头痛确实会有所波动。

And so across these hormonal milestones, migraines certainly will fluctuate, if you will.

我觉得大约三分之二的女性会在月经前后经历偏头痛，她们会发现偏头痛和月经周期有关。

I would say about two thirds of women will experience migraines with perimenstrual attacks, where they'll note an association of migraine around their menstrual period.

这种关联有两种可能的形式。

And that association comes in two possible forms.

一种是纯粹月经性偏头痛，就是只在月经期间出现头痛和偏头痛，其他时间不会。

One is women who experience pure menstrual migraine, where they experience menses and headaches and migraine occurring around their menses solely around their menses, but not at other times of the month.

这种情况比较少见。

That's less common.

大概不到百分之十的女性会经历这种纯粹月经性偏头痛，偏头痛只在月经前后出现，通常是月经前几天和月经开始后的几天。

That occurs in probably less than ten percent of women who experience what's called pure menstrual migraine, where the migraine are just around the menstrual period, usually a couple days before and a couple days into.

那当然就是激素水平最低的时候，这说明激素水平下降是导致那一部分偏头痛的原因。

Which of course is the lowest period of hormones, which suggests hormone deprivation is driving that subset.

对。

Correct.

而月经相关性偏头痛，大约有百分之五十的女性会经历，这种偏头痛不仅会在月经期间发作，在月经周期的其他时间也会出现。

And then menstrual related migraine, which is present in about fifty percent of women, is where they experience migraine not only in temporal association with their menstrual period, but at other times of the month.

所以这对女性来说是非常常见的现象。

And so this is a very common occurrence for women.

追溯到上世纪七十年代的研究，雌激素在黄体晚期自然下降与偏头痛的发生有关。

The estrogen that dates back to the nineteen seventies studies that were looked at, that natural decline in estrogen in the late luteal phase and the development of migraine.

如果快进到现在，我们从研究中了解到，正是黄体晚期雌激素下降速度更快，这在经历偏头痛的女性中是独特的。

If we fast forward in time, what we know from studies is that it's the faster rate of estrogen decline in that late luteal phase that is unique in women who experience migraine.

所以就是雌激素下降的速度更快。

So it's this more rapid rate of decline in estrogen.

我很自豪，因为我曾经有幸指导过的人之一，实际上做了这些研究。

I'm very proud because one of the people I was fortunate to mentor actually did those studies.

我很惊讶，排卵后我们没看到这种情况，因为排卵后雌二醇也会急剧下降。

I'm surprised that we don't also see that post ovulation because you also have a very sharp decline in estradiol post ovulation.

她们好像有两个下降期。

They kind of have two.

排卵后下降得很厉害，但黄体期末期就没那么明显了。

They're sharp after ovulation and then not as sharp at the end of the luteal phase.

那排卵期中间有没有观察到什么变化？

Did they see anything mid cycle?

有趣的是，在排卵期附近，似乎并没有显著增加偏头痛的风险。

So interestingly, around ovulation, there doesn't necessarily seem to be a much higher risk of developing migraine.

我想这 partly 是因为黄体晚期雌激素下降速度更快，这才是关键所在。

I think that's in part to this more rapid, faster rate of decline of estrogen in that late luteal phase, which is the unique part.

对。

Yeah.

也可能是孕酮的问题，因为排卵后孕酮并没有升高。

It could also be the progesterone because we don't see Progesterone hasn't risen in ovulation.

大家可能都知道这一点，不过为了照顾听众，我还是简单提一下。

You know this, but just for the listener.

所以排卵后我们看不到孕酮骤降，但在黄体后期，雌激素和孕酮都在下降。

So we don't see a progesterone crash post ovulation, whereas post luteal we're seeing both estrogen and progesterone come down.

那有没有可能是它们两个一起，或者说是孕酮在起作用呢？

So is it possible that it's the combination of them or the progesterone that's causing the problem?

目前大家普遍认为是雌激素，就是雌激素下降，但关键不是下降本身，而是下降的幅度和速度，这在容易偏头痛的女性中尤其明显。

Right now the belief is really the estrogen, that decline of estrogen, not the decline per se, but the degree and rapidity of decline that is unique mostly in women who experience migraine.

另外还有几点值得考虑，我们知道雌激素会影响血清素的传递。

The other couple things to end up thinking about is we know estrogen can have effects on serotonin transmission.

而血清素和偏头痛有关。

And so serotonin is involved in migraine.

对吧？

Right?

如果追溯到上世纪四十年代，当时血清素首次在血液中被发现，再到后来，人们发现偏头痛发作时血液中的血清素水平会降低，而恢复期又会回升。

If I go back to the nineteen forties when serotonin was first discovered in blood and then fast forward, serotonin was identified and noticed to be lower in blood during migraine attacks and then the recovery phase would increase.

这些研究最终促成了曲普坦类药物的研发。

Those studies ended up leading to the development of triptans.

所以雌激素在疼痛通路中扮演着多种角色。

So estrogen has a number of different roles to play in the pain pathways.

有没有做过这样的实验，就是找一些容易偏头痛的女性，在预期会发作的那段时间，专门给她们补充雌激素？

Has the experiment been done where you take susceptible women and you selectively give them estrogen during the period of time in anticipation of that?

比如说，排卵后七天，那时候雌激素水平最高，马上就要降到月经期了，给她们补充生理剂量的雌激素，这样能不能降低偏头痛的风险？

So for example, seven days post ovulation, which would be peak estrogen as it's about to crash into menses, you give them physiologic estrogen replacement levels and does that mitigate any of this risk?

对。

Yeah.

确实有人做过这样的研究，也真的给过雌激素。

So estrogen has been given, those studies have been done.

难点在于很难预测谁会有效果。

The hard part is predicting necessarily who is going to respond.

有些女性偏头痛确实会好转。

So there are some women that will get improvement in migraine.

有些可能没什么改善，还有些女性如果吃复方激素避孕药，偏头痛反而可能加重。

There are some women they may not get improvement, and there are some women who will take combined hormonal contraceptives, and they may get worsening of their migraine.

所以很难分辨出到底哪个人会有效果。

And so it's very hard to tease apart and know who's the individual that will necessarily respond.

在照顾这些患者时，我尝试做的一件独特的事情是，实际上采用协作护理模式，与一位专门研究激素的妇科医生合作。

In caring for those patients, one of the things that I try to do that's unique is actually in a collaborative care model, work with a gynecologist who is a specialist on hormones.

所以我们一起合作，实际上尝试为每位患者制定一个计划。

And so working together, we actually try to end up mapping out a plan for individual patients.

关于遗传易感性，我们还知道哪些其他信息？

What else do we know genetically about predispositions?

如果父母患有偏头痛，他们的孩子是否更有可能也患有偏头痛？

Are people whose parents sufferers of migraines more likely to be sufferers themselves?

是的。

Yes.

人们问我为什么他们会得偏头痛。

People ask me why they have migraine.

如果他们的父母在场，我通常会指着他们说：“你就是原因。”

If their parents in the room, I usually point to them and they say, You're the cause.

不是要责怪谁。

Not to place blame.

不，当然不是，但我们认为这很大程度上是遗传的。

No, of course, but we think it's very, very highly genetic then.

对。

Correct.

但是已经发现了许多与偏头痛相关的基因，所以并不是某个特定的基因。

But there are many genes that have been identified for migraine, so it's not a specific gene.

没错。

Right.

所以是多基因遗传，但遗传性很强。

So it's polygenic, but highly hereditary.

对。

Correct.

而且，偏头痛患者的神经系统，可以说比没有偏头痛的人更容易兴奋。

And the nervous system, if you will, of people who have migraine is more hyperexcitable than people who don't have migraine.

所以并不是声音更亮，而是感知，或者说敏感度提高了。

So it's not that there's more lighter sound, but the perception, if you will, the sensitivity has just increased.

这个问题可能有点傻，你可能没想过，但这对进化有什么好处吗？

Maybe a silly question you haven't thought of, but is there an evolutionary benefit to it?

不是说这在自然选择中占很大比重，但这种过度兴奋有没有什么好处呢？

Not that this would have weighed heavily in selection, but is there an upside to the hyperexcitability?

在个体不发作的时候，它会不会在其他积极的方面表现出来？

Does it manifest itself in other positive traits during the period of time when the individual's not suffering?

我的问题是这样的：如果我们在一个兴奋性的连续谱上，当它过头了，你就会头痛，这当然不好。

My question is through the lens of like, Hey, if we're on a continuum of excitability and when the thing goes too far, you end up with a headache and that's bad.

但如果你从边缘稍微退一步，那种状态有没有什么好处呢？

But if you pull back just a little bit from the brink, is there some benefit to that state?

我有个同事几年前写过这方面的文章，她推测这对女性尤其有进化上的好处，因为如果她们是家里的照顾者，她们能预知恶劣天气、暴风雨，或者危险的迹象。

So a colleague of mine ended up writing about this a number of years ago where she postulated that the evolutionary benefit to women in particular may have been, if they're the caregivers of their family that they would know if there was inclement weather coming, rainy storms, if they had end up, signs of danger.

所以这可能是进化上的一个好处。

And so that may be one of the evolutionary benefits.

另外，如果想想男性和女性的神经网络，一般来说，女性比男性需要更多的多任务处理。

The other thing is, you know, if I think about the neural networks in men versus women, women generally have to multitask much more than men in general.

所以问题是，神经网络是不是真的更好。

And so the question is whether the neural networks, if you will, are better.

这太有意思了。

That is super interesting.

所以有一种说法是，女性可能天生更擅长多任务处理，而偏头痛只是这种能力极端化的一种表现，如果你把人群往那个方向推，就会出现这种情况。

So one of those says, look, women might be more wired to be better at multitasking and the migraine is just a manifestation of an extreme, more extreme version of that, which you're going to get if you shift the population over that way.

然后第二个问题，大概是通过气压变化引起的，这是最常见的天气相关诱因吗？

And then the second issue is presumably through changes in barometric pressure, is that the most common weather related triggering event?

诱因不是头痛的原因。

Triggers are not the cause of the headache.

诱因是那些会让天生容易头痛的人引发头痛的因素。

Triggers are factors that will elicit a headache in somebody who's biologically predisposed.

也就是说，如果一个人天生不容易得偏头痛，那么即使有暴风雨来临，他们也可能不会经历偏头痛。

So meaning if somebody is not biologically predisposed to having migraine, then there may be a weather storm that's coming through, and they may not experience a migraine.

但对于有偏头痛的人来说，他们可能有一个或多个诱因。

But in somebody who has migraine, they may have one or more triggers.

有些偏头痛患者没有诱因，有些则有多个诱因。

Some people with migraine have no triggers, others have multiple triggers.

天气变化、压力后的放松现象、喝酒或吃某些特定食物都可能诱发。

Changes in weather, the letdown phenomenon after stress, drinking or eating certain types of foods that may trigger.

而且通常需要两个或更多诱因叠加才会引发偏头痛发作。

And it's usually a combination of two or more triggers that will precipitate an attack of migraine.

您是否了解，哪些患者群体确实会受到天气变化和气压波动的影响？

Do you have a sense of what subset of patients are indeed triggered by weather patterns and changing barometric pressure?

这因人而异。

It varies from person to person.

我的患者群体通常症状更严重，因为他们大多每月头痛十五天以上。

My patient population is one that generally suffers more because it's more so in the people who are experiencing fifteen or more days of headache per month.

所以可能存在报告偏差。

And so that reporting bias may occur.

我听到这类情况的频率可能比别人更高。

I may hear that more often than others may.

这倒是挺有道理的。

That kind of makes sense.

那受影响更严重的人，他们的诱因是不是也更多样化呢？

The more severely impacted people would presumably have more diversity in their triggers as well?

没错。

Correct.

有可能，但也不一定。

They may, but not necessarily.

这也正是偏头痛很复杂的地方。

And that's what makes migraine very nuanced, if you will.

所以病史采集必须非常详细。

That's why the history needs to be detailed.

所以病人填的问卷有15页，内容非常详尽，就是为了判断是原发性头痛还是继发性头痛。

So the questionnaire that people are filling out for me are 15 pages, pretty extensive in trying to end up determining if I'm dealing with a primary or secondary headache.

如果是偏头痛，那具体表现是什么样的？

And then if it's migraine, how does it present?

因为头痛日记可能是你的听众能做的最重要的事情，不仅对他们自己有好处，因为那真的能让患者更有掌控感，而且对我这样的临床医生来说，也能帮助理解，因为每个人的模式可能都不一样。

Because a headache diary is probably the most important thing that your listeners can do for not only themselves because it really empowers patients, but for a clinician like me to understand, because the patterns may be different from person to person.

你的网站上有在线版本供患者下载吗？

Do you have an online version on your website that patients can download?

有的。

Yes.

好的。

Okay.

那我们会在节目笔记里放上链接，这样任何听到这个节目的人，如果想记日记，知道该记些什么，就可以直接用了。

So we'll link to that in the show notes so that anybody listening to this who wants to actually have a diary and know what things to put in the diary, they can do it.

我同意。

I agree.

你知道吗，挺有意思的。

You know, it's funny.

我们生活的这个世界，特别痴迷于高科技的东西，比如睡眠追踪器之类的。

We live in this world where we're so obsessed with really high-tech things and sleep trackers and all these things.

但说实话，如果你去看睡眠医生，他们会让你认真做一份纸笔的睡眠日记。

But honestly, like a sleep doctor, if you go and see a sleep physician, they're going to want you to do a really good pen and paper sleep diary.

我们仍然会把这种日记给那些睡眠问题最严重的患者，因为它捕捉到的信息要丰富得多，而且与实际情况在时间上更紧密相关。

And we still give those to our patients who are in the biggest distress around sleep because the information it captures is so much more rich, so much more temporally related to what's happening.

而且，花两周时间辛苦记录，比两年的追踪器数据更有价值。

And two weeks of painstakingly doing this will offer more than two years of tracker data.

听起来对你来说，做好一份日记也很重要。

Sounds like very similar for you in getting a good diary.

当然，考虑到头痛的频率，可能需要超过两周的时间。

Obviously, might take more than two weeks given the frequency of the headache.

对。

Yeah.

通常我们会看几个月的时间，特别是如果女性提到偏头痛和月经周期有关。

Usually, we're looking at a period of several months, particularly if it's a woman who's reporting a relationship between their migraine and menstrual period.

因为最终要诊断经期偏头痛，无论是纯经期偏头痛还是与月经相关的偏头痛，这种关联至少要在三个周期中的两个周期里被观察到。

Because ultimately to make a diagnosis of perimenstrual migraine, whether it's pure menstrual or menstrual related migraine, that association is noted in at least two out of three cycles.

说到十年前第一次联系我们的那位患者，我印象很深的一点是，她当时是更年期患者，大概五十多岁快六十岁的样子。

Obviously thinking about the patient that first connected us ten years ago, one of the things that stands out about me, because she was a menopausal patient, this was a woman who at the time was in her probably late 50s, early 60s.

她用了激素之后效果不错，但剂量不能太大。

She did better on hormones but it couldn't be too much.

那个界限非常非常微妙。

There was a very, very fine line.

也就是说，我们最终给她用了雌二醇和孕激素，就像对待围绝经期女性那样，但剂量比通常治疗要低。

In other words, we ended up having to use estradiol and progesterone as you do in perimenopausal women but less than you would normally have treated someone.

换句话说，我们不能给她用到完全的治疗剂量。

In other words, we couldn't take her to full therapeutic dose.

这在更年期女性中常见吗？

Is that common in menopausal women?

从围绝经期到更年期的这个过渡阶段，不仅激素水平在波动，偏头痛也在变化。

Those transitions, if you will, from perimenopause to menopause, not only are hormonal fluctuations are occurring in perimenopause, but so is migraine.

所以像这样的患者在围绝经期，有些女性的偏头痛会明显加重。

And so in a patient like that during perimenopause, there are women that will experience a significant worsening of migraine.

大概有三分之二的女性，在进入绝经期、完成围绝经期之后，会发现偏头痛有所改善。

Probably about two thirds of women who, after they've transitioned to menopause, they've finished perimenopause, they will notice improvement in migraine.

但百分之十到二十的人可能要么继续有偏头痛，要么变得更严重。

But ten to twenty percent may actually either continue or get worse.

我发现有个误区，有些病人被告知，一旦绝经了，就没事了，不会再偏头痛了。

I find that there's a fallacy where some patients are told that once you hit menopause, you're finished, and you're not gonna have migraine anymore.

难就难在，这不只是激素波动的问题，还会影响其他症状。

And the hard part becomes is it's not only the hormonal fluctuations, but the impact on other symptoms.

比如可能睡眠会受影响。

So there may be sleep disruption.

还可能有其他疼痛，比如关节痛。

There may be other pains, joint pains.

所以这些风险因素会让人更容易频繁偏头痛。

And so there are risk factors that put one at greater risk for more frequent migraine.

如果一个人每个月有五天或更多天头痛，那风险就更高了。

If somebody experiences five or more days of headache per month, they're at greater risk.

睡眠不好，情绪波动，这些在围绝经期进入更年期时都可能出现。

Sleep disturbance, changes in mood which can end up happening in perimenopause going into menopause.

所以所有这些因素都可能直接或间接地产生影响。

So all of these things have either direct or indirect impacts potentially.

这样一来事情就变得很复杂了，因为除了考虑激素替代疗法的各种理由之外，你还得考虑，如果你属于那些在更年期症状有所改善的女性群体，那么增加激素可能会让情况变得更糟。

I mean, this just makes it a very complicated thing because now in addition to all the reasons you would consider HRT, you have to then consider if you're in that group of women who are improving in menopause, presumably adding hormones makes you worse.

不一定。

Not always.

我的意思是，除非你

Mean, unless you

找到了那个最佳平衡点，就像我们在这位患者身上做的那样，我们可以给予大约三分之二的激素水平，而不会让情况恶化，同时还能保留大约三分之二的疗效。

figure out that sweet spot like we did in this patient where we could still give hormones to maybe two thirds of the level without making it worse and then still capturing two thirds of the benefit or something.

是的，就像这位患者一样，有些女性不一定需要激素替代疗法或相关的激素治疗，而另一些女性，即使尝试了非药物和药物的方法，最终还是需要激素替代疗法。

Yeah, there are just like in this patient, there are some women who will not necessarily need HRT or hormone related therapy, and there are others that despite best efforts with non medication medication approaches will need HRT.

难点在于，正如你指出的，这变得非常个体化。

The hard part becomes is, like you're pointing out, it becomes very individualized.

对一个人有效的方法和剂量，对另一个人可能就没用，剂量太大可能会加重症状，剂量太小又可能达不到缓解的效果。

What may work, what dose may work for one person may not work for another and too much may potentially exacerbate versus too little may not end up providing the relief that's needed.

对。

Yeah.

关于偏头痛的表现和易感性，还有什么要说的吗？

Anything else about presentation and susceptibility of migraine?

我想接下来简单聊聊紧张性头痛，如果还有内容的话，然后再说丛集性头痛。

I want to then talk briefly about see if we have anything to finish on tension and then get the cluster.

好的。

Yeah.

关于偏头痛的表现，我们之前提到了几个阶段，但并不是每个偏头痛患者都会经历所有阶段。

So I think presentation of migraine is, we spoke about a couple of the phases and not all people with migraine have all the phases of migraines.

第一阶段是前驱期，也就是暴风雨前的平静，大约有四分之一到三分之一的人会有先兆。

The first phase is that premonitory phase, the calm before the storm, and a quarter to a third of people experience aura.

然后是偏头痛发作期，但不仅仅是疼痛。

And then it's the migraine phase, but it's not just the pain.

它可能是一系列症状的组合，比如怕光、怕声音、恶心。

It is potentially a constellation of symptoms, that light sensitivity, the sound sensitivity, nausea.

还可能有自主神经症状。

It may be autonomic symptoms.

所以如果一个人眼睛流泪或发红，或者鼻塞流鼻涕，人们常常会以为自己是所谓的“鼻窦性头痛”，但其实根本没有鼻窦性头痛这回事。

So if somebody has tearing or redness of the eyes or congestion running of the nose, often people think that they have, quote, a sinus headache, but there's no such thing as a sinus headache.

有急性鼻窦炎。

There's acute rhinosinusitis.

有慢性鼻窦炎。

There's chronic rhinosinusitis.

但根据偏头痛的病理生理学，副交感神经系统的一个方面参与其中，它与三叉神经有联系，而三叉神经是偏头痛和头痛体验中涉及的主要神经。

But based on the pathophysiology of migraine, there is involvement of an aspect of the parasympathetic nervous system that has a connection, if you will, with the nerve called the trigeminal nerve, which is the main nerve that's involved in the experience of migraine and headache.

当人们的副交感神经系统被激活时，可能会出现流泪、眼睛发红、鼻塞或流鼻涕，这在偏头痛患者中很常见，而他们却以为自己得了所谓的“鼻窦性头痛”。

And when people's parasympathetic nervous system becomes activated, people may experience tearing or redness of the eye or congestion or ringing of the nostrils, which is pretty common in people with migraine, and they think they have, quote, a sinus headache.

最后，在疼痛消失之后，他们可能会经历头痛后期，也就是疼痛虽然没了，但感觉还没恢复过来。

And then ultimately, at the end of the day, after the pain is gone, they can experience a postdrome, which is the pain is gone, but I don't feel back to myself.

我感觉像宿醉一样，这种感觉可能持续几个小时，甚至好几天。

I feel hungover, and that can last for hours up to even a couple of days.

所以当我问诊偏头痛病史时，我想了解它对生活的整体影响。

And so when I take a history of migraine, I wanna understand what's the total impact.

也就是说，如果他们经历了所有阶段，每个阶段持续多久？

Meaning, if they experience all the phases, what is the duration of each of them?

对个人的影响是什么？

What's the personal impact?

因为我们往往只关注疼痛本身，而不一定关注整体的影响。

Because we just focus on the pain and but not necessarily the impact in totality.

另外一点是发作间期的负担。

The other thing is the interictal burden.

你提到的一点，我非常赞同，就是人们如何因为预期偏头痛会发作，而提前规划他们的计划和日常活动？

One of the things that you pointed out, I really appreciate it, is how are people thinking about their plans, their daily activities in anticipation of experiencing a migraine?

也就是说，我现在没有偏头痛发作，但我不知道它什么时候会来。

Meaning, I'm not experiencing a migraine now, but I don't know when it's gonna come.

那我怎么安排假期呢？

How am I gonna plan that vacation?

这就是所谓的发作间期负担。

That's what's referred to as interictal burden.

发作间期，就是疼痛发作之间的那段时间。

Intrarietal meaning between the pain bouts.

对，就是疼痛发作之间。所以当我收集这些病史信息的时候，我会考虑怎么制定他们的急性治疗方案。

Between the pain And so that's where when I'm eliciting all these pieces of history, I'm thinking about how am I thinking about their acute treatment plan?

如果需要的话，我会怎么考虑他们的预防性治疗方案？

How am I thinking about their preventive treatment plan if they need that?

我会怎么考虑非药物疗法？

How am I thinking about nonmedication approaches?

然后把所有信息综合起来，当然，一旦病人理解了我这样整合的合理性，他们就会主导决策。

And then combining the picture together, obviously with the patient driving the decision making once they understand the rationality of I'm putting it together.

你能再多说说那些发作后的体验吗？

Can you say a little bit more about some of those postictal experiences?

有多少偏头痛患者，在疼痛消失后，基本上能恢复正常活动，而又有多少患者会经历发作后的那段时期，一两天甚至更久都恢复不到正常状态？

What fraction of migraine sufferers, once the pain is gone, are largely able to resume activity versus those that have that postictal period where they're not back to normal for a day or more?

这方面有基于人群的研究，也有基于临床的研究。

There are population based studies and there are clinic based studies that have been done.

基于人群的研究是针对普通人群的，而基于临床的研究，就像在像我这样的学术性头痛项目里做的那种。

So population based studies looking at the general population clinic based studies, like somebody would do in an academic headache program like my own.

这些数字大概在百分之六十到百分之八十多之间。

Those numbers can range anywhere from like sixty percent to in the high eighties.

但这仍然是一个很大的数字。

But it's still a big number.

确实很大。

It's a big number.

前驱症状也是一样，就像是暴风雨前的宁静。

The same thing with the premonitory symptoms, kind of that calm before the storm.

好的。

Okay.

顺便说一下，你刚才提到，我们这里讨论的所有情况中，偏头痛影响百分之十二的人口，男女比例是三比一。回到我们之前简单提过的紧张性头痛，你说那是最常见的单一原因。

Now you said, by the way, for everything we're talking about here, twelve percent of the population, three to one women to men, going back to tension, which we talked about very briefly, you said that's the single most common cause.

它和偏头痛正好相反。

It's the anti migraine.

所以它包含了偏头痛的所有特征。

So it's all the things that are migraine.

那它的患病率是多少？

What's the prevalence of that?

终身发病率或者终身……那相当高。

Lifetime incidence maybe or lifetime That's pretty high.

对。

Yeah.

很多人都会经历这种情况。

A lot of people are gonna experience that.

是的。

Yes.

好的。

Okay.

女性和男性的比例有差别吗？

Female to male difference?

基本是平分秋色。

Pretty pretty evenly split.

有哪些诱因？遗传因素有多大？

What are some of the triggers and how genetic is it?

我觉得这个名字容易让人误以为头痛就是由紧张或压力引起的，但实际上不一定如此。

I think the name lends people to think necessarily that it's just tension or stress that causes the headache, and that's not necessarily the case.

所以才叫紧张型头痛。

That's why it's referred to as tension type headache.

这种头痛的体验是，患者会有轻微的声音敏感，疼痛程度从轻度到中度，可能分布在头部周围、头部肌肉以及颈部肌肉。

And so that's the experience where people have that lighter sound sensitivity, mild to moderate pain that can be around the head, the muscles around the head, the muscles in the neck.

涉及的神经、解剖和生理机制，其实和偏头痛有重叠，因为支配面部、头部和颈部感觉的神经与偏头痛涉及的神经是相似的。

And the nerves that are involved, the anatomy and physiology, there's overlapping, if you will, because, the nerves that supply sensation to the face and the head of the neck are similar to what's involved in migraine.

有些遗传因素也是原因之一。

There are genetic factors that are responsible.

还有环境因素，另外，头部周围肌肉和神经的压痛也是一个影响因素。

There are environmental factors, and then there's pericranial or around the head muscle nerve tenderness, if you will, that's a contributing factor as well.

如果一个人有紧张性头痛，吃了1000毫克的泰诺后好转了，那这算不算紧张性头痛？

If a person has a tension headache and they take a thousand milligrams of Tylenol and they get better, do they have a tension headache?

换句话说，这么简单的非处方药就能缓解，可能吗？

Or in other words, could it respond to something as simple and over the counter as that?

是的。

Yes.

好的。

Okay.

对。

Yeah.

只要我们能确定就是紧张性头痛，因为做诊断不仅要符合标准，还要排除其他原因引起的头痛。

As long as we know that that's what it is, that it's attention type headache because making any diagnosis not only meets criteria but also that it's not attributable to something else.

好的。

Okay.

显然我们接下来会讨论这些问题的潜在治疗方法。

And obviously we're going to come and talk about the potential treatments for these things.

那我们就用丛集性头痛来收尾吧。

So let's round it out with cluster then.

那么，什么是丛集性头痛？

So what's a cluster headache?

丛集性头痛相对少见，比起偏头痛和紧张型头痛来说比较罕见，但它是世界上最痛苦的疾病之一。

So cluster headache is relatively uncommon, pretty rare relative to migraine and tension type headache, but it's one of the most painful disorders known in the world.

我有一个女病人，她把它比作没有打无痛分娩针，同时生一百个孩子。

I have a woman patient who's likened it to giving birth to a 100 babies at the same time without an epidural.

我是说，那种疼痛的剧烈程度就是如此。

I mean, that's the exquisite nature of the pain.

所以它的表现非常独特。

And so it's pretty distinctive in its presentation.

它更常见于男性，女性相对少一些。

It disproportionately affects men more often than women.

男女比例大约是3到4比1。

So that ratio that is now about three to four to one.

它的特点之一是可能有昼夜节律性。

It has characteristics where people may have a circadian periodicity.

也就是说，在一年中白天最长和最短的时期，比如一月、二月和七月、八月。

By that, I mean the longest and shortest days of the year, January and February and July and August.

患者可能会经历丛集期，在这期间每天或几乎每天发作，有时一天发作好几次。

People can experience cluster periods where they may have daily or near daily attacks, sometimes multiple attacks per day.

这种疼痛通常被描述为在单只眼睛周围、内部或后方。

And this pain often is conceptualized as in and around or behind one eye.

它几乎总是固定在头部或面部的一侧。

It's usually almost exclusively side locked, so just on one side of the head or the face.

发作非常迅速。

The rapidity of onset is very quick.

和偏头痛不一样，偏头痛通常是慢慢加重的，而丛集性头痛大概在五到十五分钟内就会达到疼痛高峰。

Unlike migraine, which generally will gradually build up, cluster headaches peak within about five to fifteen minutes.

发作一般持续十五分钟到三个小时不等，疼痛可以是刺痛、钻痛，非常剧烈，而且来得快去得也快。

The attacks generally last anywhere from fifteen minutes up to three hours and can be characterized as stabbing, boring, exquisite in nature, and then as soon as it came can often be as soon as it goes.

伴随疼痛，患者还会出现一些非常典型的表现。

And with the pain, people can end up getting very characteristic features.

大约百分之九十七的患者会出现同侧眼睑下垂、眼睛流泪或发红，以及同侧鼻孔堵塞或流涕。

About ninety seven percent of patients can experience a droop of the eyelid on that side, a tearing or redness of the eye on that side, congestion or running of the nostril.

所以不仅你能从患者脸上看出痛苦，而且往往还能直接看到这些视觉上的症状。

And so not only can you see the experience on the person's face, but you could actually see the visual symptoms often.

大约百分之九十的丛集性头痛患者在发作时会感到坐立不安，无法安静地坐着。

And about ninety percent of people with cluster headache can experience a sense of restlessness with the attacks where they can't sit still.

他们需要来回走动。

They need to move about.

这和偏头痛正好相反，偏头痛患者大多喜欢保持不动，或者躺在一个黑暗、安静的房间里。

That's in contrast to migraine where the vast majority prefer to be still or lie down in a dark, quiet room.

所以这些症状表现非常非常独特。

And so the presentations are very, very distinctive.

而且丛集性头痛还有个外号叫“自杀性头痛”，不仅因为疼痛剧烈，还因为发作频率非常高。

And where cluster headache, it's also been nicknamed suicide headache, not only because of the intensity of the pain, but the frequency of which these attacks occur.

平均来说，患者每天可能会发作三次。

So on average, people can experience three attacks per day.

诊断标准允许患者每隔一天发作一次，最多每天八次，而且这些丛集期根据个人情况可能持续几周到几个月，有时甚至更长。

The criteria allow people to have one attack every other day, up to eight attacks per day, and these cluster periods could be, depending on the person, weeks to months, sometimes longer.

所以这取决于患者是 episodic 丛集性头痛，也就是有丛集期然后有间歇期，还是慢性丛集性头痛，完全没有间歇期，每天多次发作。

So depending on if somebody has episodic cluster headache, where they get this cluster period and then a break in time, or chronic cluster headache, where they have no break at all, they're just having multiple attacks per day.

“自杀性头痛”这个说法是不是因为疼痛极端时，人们会想要结束自己的生命？

Does the term suicide headache stem from the fact that people will take their life if it's extreme enough?

是的。

Yes.

那太可怕了。

That's terrifying.

这是否意味着想要动一动能带来一些缓解？

Does that suggest that the drive to move provides some relief?

我不确定想要动一动是否真的能带来缓解，不如说丛集性头痛发作时大脑中某些区域的活动会导致一些症状表现。

I don't know if the drive to move provides relief as much as areas in the brain that are involved during the attack of cluster headache can cause manifestation of symptoms.

其中一种症状表现就是坐立不安或烦躁的感觉。

And one of those manifestation of symptoms is a sense of restlessness or agitation.

关于这些，我们还知道些什么？

What else do we know about these things?

这些和遗传有多大关系？

How genetic are these?

我们知道

We know

遗传因素在丛集性头痛中也起作用。

that there are genetics that play into cluster headache as well.

一级亲属可能风险更高。

First degree relatives may be at higher risk.

就像我说的，这种情况不常见，但这些患者非常积极，就像偏头痛患者一样，甚至可能更积极，因为这种疼痛非常剧烈。

Like I said, it's not common, but these are very highly motivated patients just like migraine, but maybe even more so because of the exquisite nature.

和偏头痛一样，由于疼痛的表现形式，他们也常常被漏诊或误诊。

They also, like migraine, often go underdiagnosed or misdiagnosed because of the presentation of pain.

因为发作可能偏好在一月和二月发生。

Because it can be a predilection for attacks to occur January and February.

所以人们可能会在那段时间去看医生，说我有疼痛、鼻塞，然后可能被告知是鼻窦感染，接着就开了抗生素。

So people may come into their doctor at that period of time, say that I have pain, I have nasal congestion, and they may be told, oh, you have a sinus infection, then receive an antibiotic.

到了七月和八月，他们可能会去看医生，说我有疼痛、流泪、眼睛发红，然后可能被告知是过敏。

July and August, they may come to their doctor and say, I have pain, tearing, redness of the eye, and they may be told, you have allergies.

你需要打过敏针。

You need allergy shots.

有些人会有牙齿或面部周围的疼痛，他们可能拔过牙，或者做过大手术，或者鼻窦手术，却没有意识到这些症状实际上是丛集性头痛。

Some people will have pain that's around the teeth or the face, and they have had teeth pulled or major dental surgery or sinus surgery without realizing that the presentation is actually cluster headache.

你网站上提供的日志，人们可以下载，用来记录准确的病史，如果他们头痛的话，他们能把这个带给他们的初级保健医生吗？

Part of the log that people can download from your site that allows them to take an accurate history, Is that something they could take into their primary care physician if they're having a headache?

这份日志里有没有足够醒目的提示，让医生意识到这可能是丛集性头痛？毕竟找头痛专科医生不容易，要么是因为他们数量少，要么是因为就诊频率低。但为了避免误诊、避免把没病的人当成有病来治，花点时间找到对的医生是非常值得的。

Does it highlight enough for the doctor the flag that says, Hey, this might actually be a cluster headache and this might be one of the times when, even though it's hard to get to headache specialists because of the frequency or the low number of them, it's worth taking the time to get the right clinician on board before we make a mistake and treat you for something you don't have.

对。

Yes.

我觉得这点特别重要。

I think that becomes very important.

我常想到我的全科同事，他们在那么短的时间里要处理那么多事情。

I think about my primary care colleagues and the number of things that they have to address in a relatively short period of time.

头痛可能只是其中一种症状，我觉得这才是难点所在。

And headache may be just one of them, I think that's the hard part.

所以我们希望给患者提供大量资料，这样他们去看全科医生时，就能帮自己把情况说清楚。

So we want to kind of arm patients with a ton of data so that when they meet their PCP, they can do the lifting for them.

全科医生通常只有十分钟时间，没法像专科医生那样做详细的病史询问。

The ten minutes that that primary care doc has, they're not going to be able to do the detailed history you would do.

但如果患者带着这些资料去，医生通常会很乐意接受，并说：哎呀，太好了。

But if they can walk in with it, hopefully the doctor is receptive and says, Oh gosh, yeah.

我根本没有时间去问这些，甚至可能连问这些的知识储备都没有。

I wouldn't have had the time to elicit this or wouldn't have even had the knowledge base to elicit

对。

it.

我正想说，不只是医生愿不愿意接受，关键是时间。

I was about to say, it's not only receptive, it's the time.

还得有足够的知识、教育和经验来做出诊断，然后提供合适的治疗方案。

It's also having the knowledge and education and experience to make the diagnosis and then offer the appropriate treatments.

所有条件都得凑齐才行。

All the stars need to align, if you will.

大多数头痛患者来就诊时，不是第一次来找我，有时候也有，但他们通常先去初级保健医生那里。

Most people with headache, if they're coming in, they're not coming to me for the first time, sometimes they do, but they're often going to their primary care.

所以那是个入口。

So that's the gateway, if you will.

难就难在入口之后的导航，尤其是当他们没有诊断或者被误诊的时候。

The hard part becomes is kind of navigating afterwards the gateway, particularly if they don't have a diagnosis or they're misdiagnosed.

而且病人从各地来找你看病。

And patients come and see you from all over the place.

世界各地都有。

All over the world.

对。

Yeah.

那显然意味着很多人在痛苦发作的时候没法见到你。

That means that obviously a lot of them can't see you when they're in the throes of suffering.

这有关系吗？

Does that matter?

对于丛集性头痛患者来说，这就像是我诊室里的通行证。如果是一个老病人或者想来看病的人，他们会说自己有丛集性头痛。

So for patients with cluster headache, that's kind of the password, if you will, in my office, in the sense that if somebody who's either an established patient or somebody who's trying to get in, they will say that they have cluster headache.

如果事实上，至少根据问卷上勾选的信息暗示了这种可能性，那么他们通常会被更快地接诊，因为这种病有个外号叫“自杀性头痛”。

If in fact they, at least on the basis that a questionnaire seem to check off information that alludes to that possibility, then yes, they're seen quicker in general just because it's been nicknamed suicide headache.

你见到他们，对做出诊断或治疗决定有帮助吗？

Is there a benefit to you seeing them while to make a diagnostic or treatment decision?

原因通常是丛集性头痛患者需要多种治疗。

The reason why is often patients with cluster headache require multiple treatments.

一种是急性治疗，也就是当他们发作时，用治疗来快速止痛。

One could be acute treatment, meaning when they experience the attack, they're using a treatment to rapidly abort the pain.

另一种是预防性治疗。

The other is a preventive treatment.

所以他们要服用一种或多种药物来预防发作，因为这类患者常常一天发作多次，持续几周到几个月，然后还有过渡性治疗。

So they're taking something, one or more things to prevent attacks because often these patients with cluster headache are experiencing frequent attacks a day over a period of potentially weeks to months, and then transitional treatment.

预防性治疗通常需要几周到几个月才能起效，即使是偏头痛也一样。

The preventive treatments often take weeks to months to build up, even for migraine.

那么在过渡期该怎么做呢？

And so what is being done in the transitional period?

抱歉打断一下，布莱恩。

Sorry to interrupt, Brian.

你说预防性治疗，是指改变饮食这类生活方式上的预防，还是指需要长期服用的药物预防，来降低发作的可能性？

When you say preventive treatments, do you mean lifestyle preventive treatments like changing diet or do you mean actual pharmacologic prophylactic drugs that you need to just have on board to reduce the probability of an attack?

对。

Yeah.

所以需要多学科综合治疗。

So a multidisciplinary approach.

也就是说，对于丛集性头痛患者，一些例子包括避免饮酒、避免含有硝酸盐的食物、最好白天不要小睡。

So meaning for patients with cluster headaches, some of the examples would be avoiding alcohol, avoiding foods with nitrates, not taking naps during the day preferably.

如果他们有睡眠呼吸暂停，要解决这个问题，因为缺氧有时也可能与之相关。

If they have a sleep apnea, addressing that because hypoxia can sometimes be associated with it as well.

同时，预防性治疗是使用药物，可能需要时间才能起效，在起效期间，提供一些方法快速抑制发作，直到预防性治疗发挥作用。

And then at the same time, preventive treatment is taking up pharmacological, right, a medication treatment that may take time to build up, and while that is being built up, offering something to try to rapidly suppress the attacks until those preventive treatments kick in.

对。

Yeah.

好，那我们借此转到你刚才提到的第一点，也就是你会为这些患者保留哪些可调整的生活方式干预措施，这些措施对所有头痛类型都一样吗？

Well, let's use that to pivot to the first thing that you talked about there, which is what are the modifiable lifestyle interventions that you would keep in your playbook for these patients and are they the same across all the headaches?

你刚才说的比如纠正睡眠呼吸暂停、减少饮酒、避免白天小睡，这些建议你会给所有头痛患者吗？还是主要针对丛集性头痛患者，而对偏头痛患者有不同的方案？

Everything you just said for example around correcting sleep apnea, minimizing alcohol, avoiding naps during the day, would you give that advice to any person suffering from headache or are you really narrowing that on the cluster patient, whereas the migraine patient, you have a different playbook?

偏头痛本身有一些已知的风险因素。

Migraine itself has certain identified risk factors.

甚至偏头痛的亚型也可能有各自的风险因素。

Even the subtypes of migraine may have their own identified risk factors.

所以，如果我们从研究中得知，如果一个人每周至少发作一次偏头痛，超过这个频率可能会增加他们更频繁发作的风险。

So if we know from studies that were done that if somebody is experiencing at least one migraine a week, more than that may put them at greater risk for more frequent attacks of migraine.

所以，基线时发作频率越高，可能导致偏头痛的慢性化或转化，使发作更频繁。

So the higher the frequency of attacks at baseline maybe lead to chronification or transformation of more frequent migraine.

那些生活中压力事件多的人。

Somebody who has stressful life events.

对吧？

Right?

我们都有压力，但这也是一个风险因素。

We all do, but that's a risk factor as well.

睡眠障碍。

Sleep disturbance.

可能是失眠。

That may be insomnia.

也可能是睡眠呼吸暂停。

That may end up being sleep apnea.

所以再说一次，这些都是可以调整的。

So once again, modifiable.

一个人的情绪、抑郁、焦虑，都和偏头痛有关。

Person's mood, depression, anxiety are comorbid with migraine.

它们同时出现的概率比偶然要高，而且情绪障碍和偏头痛之间是双向影响的。

They coexist at a higher than expected by chance, and there's a bidirectional relationship between mood disorders and migraine.

所以处理这些问题，这就是为什么我尽量跟病人解释，所有因素都得配合好。

And so addressing those, that's why I try to explain to patients that all the stars kinda need to align.

不只是处理疼痛，我们还得解决这些风险因素。

It's not just taking care of your pain, but we need to end up addressing these risk factors.

经常使用急性止痛药的人。

People frequently using acute pain medications.

有些止痛药，如果每周规律使用两天以上，并且持续一段时间，实际上可能会让头痛更频繁。

So there are some classes of pain medications where if they're used two or more days per week on a regular basis over an extended period of time, that can actually create more frequent headaches.

不是每个人都会这样。

It doesn't happen for everybody.

那可能是非甾体抗炎药和对乙酰氨基酚，或者抗

That could be NSAIDs and acetaminophen or anti

炎药，简单的止痛药。

inflammatories, simple analgesics.

甚至可能是曲普坦类，也就是偏头痛的特效药。

It could even be triptans, migraine specific medications.

也可能是含有巴比妥的复方止痛药，比如Fioricet或Fiorinal，还有阿片类药物。

It could be barbitric containing combination analgesics medications like Feoracet or Fiorinol, opioids.

另外，如果一个人有其他疼痛问题，肥胖也是偏头痛更频繁的风险因素，而且肥胖程度越高，风险越大。

And then if somebody has other pain disorders, obesity is a risk factor for more frequent migraine, and the greater the degree of obesity, the greater the risk.

你觉得这和炎症有关吗？

And do you think that's inflammatory?

你觉得这和胰岛素有关系吗？

Do you think it's insulin related?

可能也是多种因素共同作用的结果。

It's probably multifactorial as well.

偏头痛本身在病理生理上就有促炎成分，所以可能有一些共同的机制在背后起作用。

Migraine itself has a pro inflammatory component to its pathophysiology, and so there may be shared mechanisms that underlie that.

那这个风险可以改变吗？首先，你知道肥胖相对于不肥胖，在头痛方面的风险比或者相对风险增加是多少吗？

And is this modifiable if a person is so first of do you know what the hazard ratio is or the increase in relative risk with obesity versus not with respect to the headaches?

所以病态肥胖的人，偏头痛更频繁的风险是五倍。

So people who are morbidly obese are at five times

风险更高，偏头痛发作更频繁。

higher risk for more frequent migraine.

哦，那这可不是小问题。

Oh, so it's not subtle.

这影响确实很大。

It's This not is dramatic.

确实很惊人。

Dramatic.

而且有研究显示，无论是手术还是非手术的减重方式，都能改善偏头痛，虽然不是对每个人都有效，但确实有改善效果。

And there are studies with weight loss, surgical and nonsurgical, showing improvement in migraine, not uniformly across the board for every individual, but certainly showing improvement.

调整这个风险因素也很有帮助。

Modifying that risk factor is very helpful as well.

这些数字有些让人震惊。

Some of these numbers are shocking.

女性比例是三比一，这对我来说并不意外，因为根据我的亲身经历，我遇到的大多数偏头痛患者都是女性。

The women being three to one is not shocking with my lived experience because when I stopped to think about it, almost all of the people I've encountered with migraines or most of them are women.

我理解。

I get that.

肥胖是五倍的风险。

The obesity is five x.

这确实出乎意料。

That is surprising.

病态肥胖。

Morbidly obese.

好的。

Okay.

对，病态肥胖。

Yeah, morbidly obese.

意思是BMI达到35？

Meaning thirty five BMI?

是的。

Yeah.

对。

Yeah.

那肥胖呢？

But what about obese?

30到35呢？

What about 30 to 35?

更高

Greater

的风险。

risk.

高多少？

How much?

两倍？

2x?

两倍。

2x.

好的。

Okay.

那还是挺严重的。

Still a big deal.

对。

Yeah.

所以换句话说，如果你想找理由来纠正肥胖问题，从健康角度来看有很多，比如心脏病和癌症这类慢性病。

So in other words, if you're looking for a reason to correct obesity, there are plenty of them on a health perspective as it pertains to chronic disease like heart disease and cancer.

但当你想到两件能显著提升生活质量的事情时，一个是骨科方面的，就是你的关节磨损会少很多。

But when you think about two dramatic things that improve the quality of your life, one would be orthopedic, you just have less wear and tear in your joints.

另一个可能是对于容易受影响的人，那些头痛问题。

Then another could be for the susceptible individual, these headaches.

对。

Correct.

还有你刚才提到的其他疼痛问题，比如关节痛、脖子痛、背痛，这些都会导致……

And then having other pain disorders, which you just alluded to, whether joint pain, neck pain, back Which

让你更多地依赖药物，对。

leads you to more of the medications that Correct.

然后这些药物也成了…… 那这些在分析中有被校正过吗？

Then also become the And has that been corrected for in the analysis?

是的。

Yes.

本身就患有其他疼痛疾病，风险会更高。

Having other pain disorders in and of itself puts one at greater risk.

如果存在恶心，而且恶心没有得到很好的治疗。

Having the presence of nausea, nausea that's not optimally treated.

如果偏头痛发作治疗不当，风险也会更高。

If a migraine attack is sub optimally treated, also greater risk.

所以当我列举病史时，我几乎是在做这种计算分析，然后向人们解释，我是怎么考虑的。

So when I'm listing the history, I'm almost doing this computational analysis and then explain to people, here's how I'm thinking about it.

这就是为什么你的治疗方案会这样设计。

This is why your treatment plan is being designed this way.

而且每个人的治疗方案不一定都一样。

And no two people are gonna necessarily have the same treatment plan.

这就是你问的偏头痛和丛集性头痛的区别。

That's what you were asking in terms of migraine versus cluster.

对于丛集性头痛，我们当然会讨论生活方式的调整，但可能是一些特定的诱因，比如食物、硝酸盐、睡眠呼吸暂停、白天小睡等。对于偏头痛，我们要关注的是那些风险因素，以及如何不仅治疗偏头痛本身，还要处理这些风险因素，以防止病情进展。

Cluster headaches, certainly, we're gonna talk about lifestyle modifications, but it may be things that are particular triggers, whether it's the food, the nitrates, the sleep apnea, taking naps during the day with migraine, it's what are those risk factors and how do we address not only the disease migraine, but also those risk factors to try to prevent progression.

好的。

Okay.

我复述一下，确认我没听错。

Just to play that back, make sure I heard it.

丛集性头痛的预防性治疗主要是找出诱因。

Prophylaxis on the cluster side is around identifying the triggers.

是什么，是什么导致它发作的？

What's the what's the thing that's making it happen?

偏头痛这边，因为我们知道的急性诱因比较少，所以更多是普遍降低它发生的概率。

On the migraine side, it's because there are fewer acute triggers that we are aware of, it's more just generally reducing probability of it happening.

让我澄清一下。

Let me clarify.

对于丛集性头痛，重点不是诱因。

So for cluster headache, it's not the triggers.

那些是我可能建议他们改变的生活方式。

Those are things, lifestyle changes that I may suggest to them.

这是病理生理学和丛集性头痛的潜在机制，这些机制会在一年中的不同时间、一天或一夜的不同时间诱发发作，因为涉及睡眠-觉醒周期，这就是为什么人们会有这种年周期性和昼夜周期性，因为涉及下丘脑、松果体以及夏令时时钟的变化。

It's pathophysiology and the mechanisms that are underlying cluster headache that will precipitate attacks potentially at different times of the year and different times of the day or the night because there's involvement of the sleep wake cycle, and that's why people have this circannual periodicity and the circadian periodicity because there's involvement of the hypothalamus and the pineal gland and the changing of the clock for daylight savings time.

所以我知道，当时钟改变时，我会收到丛集性头痛患者的消息。

So I know when the clock has changed, I'm gonna hear from people with cluster headache.

春季和秋季都会吗？

In both spring and fall?

是的。

Yeah.

我的意思是，我有一个来自澳大利亚的患者，当他去那里旅行时，会因为季节变化而发作丛集性头痛；当他来这里时，如果季节不同，也会发作。

I mean, have patients I have a patient from Australia who, when he travels there, will get cluster attacks because the season's changing when he comes here if he comes with a different season.

你觉得其中有多少可以通过固定的昼夜节律来改善？

And how much of that do you think is fixable with circadian rigidity?

换句话说，如果你对患者说，看，鲍勃，我不在乎光线会改变。

In other words, if you said to a patient, look, Bob, I don't care that we're going to change the light.

我们会在你家里放一个五万勒克斯的灯，我们会确保你的垂体、下丘脑、松果体，以及你大脑的每个部分都在完全相同的时间看到光线和黑暗。再次强调，我这是作为一个思想实验，是的，是的。

We're going to get a 50,000 lux light in your home, and we are going to make sure that your pituitary, your hypothalamus, your pineal gland, every part of your brain is seeing light and darkness at the exact same Again, I'm using this as a thought experiment, Yeah, yeah.

我们要完全控制你的光照环境，不受季节影响。

We are going to completely control your light environment independent of the seasons.

那会有效果吗？

Would that have an impact?

我觉得这不会消除一个人的丛集性头痛。

I don't think that's going to eliminate a person's cluster headaches.

我觉得这样做的话，如果一个人不一定要去那些可能有季节变化的地方或时区，他们可能不会经历丛集性发作，但这并不是确定的。

I think what it will do is if you if somebody is not necessarily going to areas or time zones where there may be seasonal changes, they may not necessarily experience cluster attacks, but that's not a certainty.

你多久会采取一种经验性的方法，比如说，我们一次尝试两种干预，直到找到有效的方法？

And how often do you just take an empirical approach to this and say, like, we're gonna throw the kitchen sink at this two interventions at a time until we find things that work.

比如说，我们在处理饮食敏感问题时经常这样做。

I mean, for example, we do this all the time with dietary sensitivities.

比如，你遇到一个患者，他饱受腹胀和胃肠问题的困扰，还有自身免疫性疾病，这些病不容易查明原因。一种做法是，我给你做一堆完全虚假、胡扯、编造出来的血液检查，这些检查没有可验证的依据，然后我会给你一堆愚蠢的建议，再给你开一堆没用的补品。

So you get a patient who's just got debilitating bloating and GI issues, autoimmune conditions that aren't otherwise easy to identify and one path is I'm going to run a bunch of blood tests on you that are totally bogus and bullshit and made up and have no verifiable causes and I'm going to come up with a bunch of silly recommendations and give you a bunch of dumb supplements.

显然，这不是我们的做法，你从我的措辞就能看出来。

Obviously that's not our approach as you can tell by my language.

另一种方法看起来没那么科学，但说实话效果要好得多，那就是做排除饮食。

An alternative approach that seems way less scientific but frankly works a lot more is we're going to do an elimination diet.

我们会假设你饮食中的某些东西导致了这个问题，然后我们会选择性地、毫不留情地把这些东西从你的饮食中去掉，直到找到触发因素。

We're going to hypothesize that something in your diet is causing this and we are going selectively and ruthlessly pull things out of your diet until we find the trigger.

也就是说，先去掉，等看有没有改善，再一样一样地加回来，观察能不能引发症状。

Which means pull it out, wait for an improvement, reintroduce it one at a time and watch to see if we can precipitate it.

这样我们就能弄清楚乳制品、酒精、咖啡因、小麦这些东西各自的作用。

And this is how we will figure out the role of dairy, alcohol, caffeine, wheat, all of these things.

再说一遍，这看起来没那么科学，但比那些毫无意义的虚假指标实用多了。

Again, seems less scientific, way more practical than using bogus metrics that don't mean anything.

你在头痛治疗上也会用同样的方法吗？

Do you ever do the same thing in the headache landscape?

是的。

Yeah.

所以我工作的一个重点就是生活方式。

So a big focus of what I do is on lifestyle.

我们怎么调整那些可能引发问题或者有助于降低风险的因素，让这个人更容易成功呢？

How do we modify things that will set that person up for best success that may be triggers or that help reduce risk factors?

我尽量采取一种非常谨慎的方法。

I try to take a very calculated approach.

我也试着去了解坐在我面前的这个人。

I I also try to understand the person who's sitting in front of me.

对。

Right.

他们有多愿意去尝试实证的方法呢？

How willing are they to be empirical?

所以，关键就是诊断是什么？

So it's what's the diagnosis?

他们有没有其他并存的健康问题？

What are their coexisting medical conditions?

他们的偏好是什么？

What's their preference?

他们的期望是什么？

What are their expectations?

在开始看诊之前，我会问他们，今天我能回答的最重要的一两个问题是什么？

Before I start a visit, I ask people, what are the one or two most important questions I can answer today?

我想了解这个人的想法。

And I wanna understand the person's perspective.

仅仅给他们医学信息是不够的，我还要确保这些信息符合他们的思考方式，并且非常个性化。

It's not enough to end up giving them the medical information, but I wanna make sure it aligns with how they're thinking about it, and that it becomes very tailored.

如果我在考虑生活方式的调整，我们会关注饮食，每天规律的三餐，不推迟。

If I'm thinking about lifestyle modification, we're focusing on diet, routine meals a day that are not delayed.

如果有特定的食物诱因，我会让他们记录头痛发作的情况。

And if there are particular food triggers, asking them to track with the headache.

除非我了解这个人，否则我不一定会让他们同时戒掉所有东西。

Unless I understand the individual, I don't necessarily ask them to eliminate everything at the same time.

我还想知道是否有麸质敏感或乳糜泻的家族史，这可能会引导我去考虑让他们做相关检测。

I also wanna know if there's a family history of either gluten sensitivity or celiac disease, and so that may lead me down the path to end up thinking about them getting tested for that.

但是就像你说的，有些食物对某些人来说可能是诱因。

But there are certain, like you said, certain foods that may be triggers for certain people.

酒精也可能是诱因，但不是对所有人都这样。

Alcohol may be triggers, but not everyone.

所以我说这是非常个体化的。

And that's why I say it's very individualized.

还有睡眠的重要性、激素、环境因素、运动，以及减少诱因负担。

And then the importance of sleep, hormones, environmental factors, exercise, and reducing trigger burden.

也就是说，如果某人知道自己在某个特定时间可能容易发作，那我可能会说，好的，你可以通过做某些事情来降低这种风险。

So meaning if somebody knows that I may be set up for an attack at this particular time, then I may say, okay, you may be able to mitigate that risk by doing x, y, and z.

举个例子，人们记头痛日记，可能会在周末发作。

And an example of that is when people keep headache diaries and they may experience attacks on the weekend.

我会说，好的，那工作日期间发生了什么？

I'll say, okay, so what happens during the week?

你工作很拼命，内啡肽水平升高，然后又会降下来。

You go very hard, endorphin levels go up, and then they drop down.

然后你周五晚上睡得晚，周六起得也晚，咖啡因摄入的时间就推迟了。

And then you go to sleep later on Friday night, and you wake up later on Saturday, and your caffeine intake is delayed.

这就是三个诱因。

That's three triggers.

对。

Mhmm.

所以人们就会有那种恍然大悟的时刻。

And so then people have like the moment.

哦，我都没意识到。

Oh, I didn't realize that.

这在他们记录日志的时候特别有价值，因为你能看到工作日早上六点喝咖啡。

And this is especially valuable when they're doing the log because you can see during the week, have my coffee at six in the morning.

周六呢，我早上八点才起床，九点才喝咖啡。

On Saturday, I'm not even getting up till 08:00 in the morning and having coffee at nine.

你根本不会想到这一点。

And you wouldn't think of that.

对。

Right.

这些就是我指出的细微差别，而且我通常要求病人记录的日记是以一个月为单位的。

And those are the nuances that I point out, and usually the diaries that I ask people to keep are a month view.

这样我就能快速浏览，实际上我会把日记从病人那里拿过来，然后说，好的，我是这样理解和解读这些内容的。

And so that way I'm able to quickly glance and I actually pull the diary off into patients and I'll say, okay, here's how I'm thinking about and interpreting this.

这就是我们最终会使用这些治疗方法的原因。

This is why we're gonna end up using these treatments.

举个例子，如果有人经历经期偏头痛，这很常见，我可能会说，哦，好的。

And so an example would be if someone experienced menstrual migraine, which is quite common, I may say, oh, okay.

那你的月经期持续多久？

So your menses, how long does it last?

周期之间的间隔是多久？

What's the inter cycle length?

两个周期之间的长度是多少？

What's the length in between the cycles?

经血的特征是什么样的？

What's the characterization of the flow?

头痛和这个时间点有什么关系？

When do you experience headaches in relationship to that?

我发现每次都是一样的。

I see that it is the same every single time.

正因为如此，根据这个时间点，我们也许可以采用预防性治疗。

Because of that, that timing, we may be able to use preemptive treatment.

我们也许可以提前开始治疗，然后一直持续到你通常预期会头痛的那几天。

We may be able to actually start treatment in advance and then carry it through the days that you would normally anticipate it.

记日记这件事，不仅能让患者更有主动权，也确实有助于指导治疗决策。

The diary, it's an effort that not only empowers patients, but really helps guide decision making.

对。

Yeah.

我喜欢你讲这个，因为这很好地提醒了患者为什么要花这个功夫。

I like that you're talking about this because it's a great call out to patients for why you want to invest in this effort.

说实话，填这种日记确实有点麻烦。

Let's admit it, it's a bit of a pain to have to fill out one of these diaries.

确实。

It is.

要记下你几点上床睡觉、几点起床、月经什么时候开始、持续多久、有什么特点、什么时候喝咖啡、什么时候喝酒、什么时候工作。

To have to write down what time you go to bed, what time you wake up, when your period starts, how long it lasts, what the characteristics of it are, when you have caffeine, when you have alcohol, when you work.

我是说，要记的东西真不少。

I mean, that's a lot to keep track of.

每天都要多花二十分钟。

It's a twenty minute added burden every day.

所以我感谢大家这么做。

And I thank people for it.

对。

Yeah.

我说，听着，我知道你们在付出努力。

I said, listen, I know you're putting in effort.

但这带来的回报是巨大的。

But it pays huge dividends.

我们不需要逐一讨论每一个生活方式的调整，因为那些显而易见的方面都值得提出来。

We don't need to go through every single lifestyle adjustment because all the ones that are in the obvious category are worth stating.

每个有睡眠呼吸暂停的人都应该得到纠正。

Everyone who has sleep apnea should have it corrected.

每个人都应该锻炼。

Everyone should exercise.

每个人都应该适量饮酒。

Everyone should moderate alcohol intake.

每个人都应该保证一定的睡眠时间。

Everyone should be sleeping a certain period of time.

每个人都应该尽量固定上床和起床的时间。

Everyone should be trying to fix bedtime and wake up time relatively.

每个人都应该关注昼夜节律健康等等。

Everybody should be doing circadian health, etcetera.