SCOTTSDALE, ARIZ. – Dihydroergotamine remains underused in the treatment of migraine and daily severe headaches, especially in inpatient settings, according to Dr. Priyanka Chaudhry.
The drug offers several clinical advantages, said Dr. Chaudhry, a neurologist specializing in headache treatment at the University of Texas Southwestern Medical Center in Dallas.
Dr. Priyanka Chaudhry
When used in combination with an antiemetic such as metoclopramide, dihydroergotamine (DHE) has been found to be as effective as opiates, valproate, and ketorolac in relieving migraine headache and preventing relapses, Dr. Chaudhry said. Its bioavailability is 100% when given intramuscularly or intravenously, and about 40% when given as a nasal spray, she added.
With its relatively long half-life of 10-13 hours, DHE also poses less risk of physical dependence than does ergotamine, Dr. Chaudhry noted. And in a recent uncontrolled retrospective study, its cumulative positive effects persisted for up to 1 month after patient discharge, she said at a symposium sponsored by the American Headache Society.
Dr. Chaudhry typically starts patients on an infusion of 0.3 mg DHE given over a period of 45 minutes, and if the patient tolerates this dose, increases it to 0.5 mg, then 0.75 mg, and then 1 mg spaced every 6-8 hours, she said. When the patient is free of headaches, she reduces the dose to 0.5 mg. She prefers that patients be headache free for 24 hours before discontinuing DHE, although this goal is not always achievable, she noted.
Treatment with DHE for 5 days seems to be more effective than shorter courses, Dr. Chaudhry added. She, therefore, will admit patients to the infusion clinic for 5 days, and then readmit them later for follow-up treatment with lidocaine, she said.
Dihydroergotamine was associated with several potentially serious adverse effects. “It can be very harsh on veins, so if you’re admitting somebody in an inpatient setting, it is preferable to order a midline catheter or a PICC [peripherally inserted central catheter] line,” said Dr. Chaudhry. Patients also can experience chest pain or a feeling of warmth or pressure in the neck during DHE infusion, especially the first time they are exposed to a given dose of the drug, she noted. “This side effect is not a contraindication for use,” she emphasized. “But consider a slow infusion, and do not bolus.” She orders electrocardiograms for such patients but sees no need to monitor cardiac enzymes, she said.
Nausea is the most common side effect of DHE, and can be treated with 8 mg odansetron, said Dr. Chaudhry. She adds a second antiemetic such as promethazine on an as-needed basis, decreases the rate of DHE infusion, and cuts the dose if nothing else works, she said. Clinicians might also consider adding 50 mg hydroxyzine orally or IM every 6 hours, starting at 25 mg if patients are relatively small or sensitive to medications, she said.
Dihydroergotamine also can cause light-headedness, diarrhea, abdominal cramping, and leg cramps, Dr. Chaudhry noted. Patients who are pregnant or have renal or hepatic failure, uncontrolled hypertension, sepsis, or vascular disease, should not take DHE, she cautioned.
She said she had no relevant financial disclosures.