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In This Issue

The paper that is the recipient of the 2003 Wolff Award is published in this issue. In this article, Yarnitsky and colleagues describe an extension of their elegant research involving the mechanisms of the peripheral and central sensitization that occurs consequent to migraine. Using cutaneous allodynia as a marker of sensitization within the spinal trigeminal nucleus, the authors have demonstrated that cranial parasympathetic outflow may activate intracranial nociceptors and that the central sensitization that results will persist despite parasympathetic blockade. These observations may assist us in unraveling the skein of physiologic events that transpire during a migraine attack and perhaps lead us to more specific and effective therapeutic interventions. Also in this issue, we have included two “Expert Opinions” rather than the usual one, and both Opinions deal with the use of droperidol for the treatment of acute migraine. By 2000, parenterally administered droperidol had become the treatment of choice at our center for patients with acute severe migraine refractory to self-administered abortive medication. Because of its simplicity of administration and high efficacy, the drug subsequently established itself as the most favored treatment for acute migraine in our county’s emergency departments. With Dr. Young and his colleagues at the Jefferson Headache Center, we concluded a randomized, placebo-controlled, doubleblind study that seemed clearly to establish the safety and efficacy of intramuscularly administered droperidol for acute migraine. But . . . now comes the “black box,” containing within the grim admonition that this drug may provoke QT lengthening and potentially fatal cardiac arrhythmia. Suddenly things are not so simple. Now if I wish to administer intramuscular droperidol to a patient who has presented to our center emergently for “rescue” treatment, the normal rhythm and flow of the clinic is interrupted to accommodate our nurse performing a pretreatment electrocardiogram, my interpretation of the tracing, and a repeat of this process once treatment is completed. Given the volume of patients who confront us and the time constraints already present, intramuscular meperidine seems an increasingly attractive alternative. In their Opinions, Drs. Young, Atriham, and Nasir provide us some perspective on how to deal with this vexing situation. Unfortunately, whether it be well-justified or not, the specter of “the box” is unlikely to catalyze the use of droperidol for patients with acute disabling migraine.