Dihydroergotamine DHE For migraine headache symptoms

History:

Ergotamine blocks serotonin receptors and causes constriction of arteries—vasoconstriction. It was first used in the sixteenth century to induce childbirth and then later for migraine in 1925.  Ergotamine for acute therapy of migraine had its heyday from the 60’s till the 90’s when Imitrex injectable first came out, but are rarely used now.

A progeny of ergotamine is dihydroergotamine (DHE) which was first produced in the US in 1946.  DHE blocks serotonin receptors and causes constriction of cranial blood vessels, but mainly veins.  It has a long half-life of 9 hours.

DHE has been used as the go to acute migraine medication for patients taking too much headache medicine—medication overuse headache.  See the articles under categories on Medication Overuse Headache. 

All across America major hospitals have headache neurologists who admit patients with Chronic Migraine for IV DHE treatment.  DHE can be given IV, IM, SC, and as a Nasal Spray but is not available orally.

Starting in the fall of 2016 and until late Spring of 2017 there was a national shortage of all forms of DHE, but since about May it has been available again.

Pharmacology:

For acute migraine or cluster headache DHE may be given 1 mg SC, IM, or IV once.

For retreatment DHE may be given IM or SC 3 mg/24 h up to 6/wk; 2mg/24 h up to 6mg/wk.

The dose may be repeated IV, IM, or SC in 1 h.

Migranal is a DHE nasal spray which is about 1/6th as strong as parenteral treatment above (IV, IM, SC).  However, it is usually effective and a great relief to those who can’t learn to give themselves a shot.  However, if a patient doesn’t respond well to NS DHE, I try to get them to inject DHE IM because it is stronger.

Typical use:

DHE is another good acute therapy choice for migraine and we need all we can get.  61 % of Migranal patients experienced relief by 2 hours and 86% of responders had no recurrence for 24 hours.  Rare side effects may be nausea and leg cramping, see the Product Information sheet for a list of possible side effects.

An important point is that DHE should not be used within 24 hours of triptan use.

I use Migranal nasal spray for patients with medication overuse headache, where they may need it for several weeks while they detox from all the pain killers they have been taking and they need something for episodes of acute headache that won’t worsen their situation.  I also use it for patients who get into trouble taking triptans more than 2 days a week and I ask them to limit the triptan use to 2 days only and then take DHE for a third headache day in a week, as long as it is 24 hours since they have taken a triptan.  These patients all need to be doing the migraine lifestyle and on a preventive drug.

After they get back to episodic migraine, some patients prefer DHE NS over triptans.

Using DHE this way I very rarely have to admit patients with headache but see them in the office.