What are the dosage and usage guidelines for ergotamine medication?

Ergotamine Medication Dosage and Usage Guidelines

Ergotamine should be administered at the first sign of a migraine attack, with a maximum of 6 tablets per attack and no more than 10 tablets per week to avoid medication-overuse headaches and ergot toxicity. 1, 2

Types and Formulations

• Ergotamine tartrate is available in oral sublingual tablets and rectal suppositories (often combined with caffeine as Cafergot) 3
• Dihydroergotamine (DHE), a semisynthetic ergot alkaloid, is available in parenteral (IV/IM) and intranasal formulations 3, 4

Dosage Guidelines for Ergotamine Tartrate

Oral Administration

• Sublingual tablets: One 2 mg tablet under the tongue at first sign of attack, with additional tablets at 30-minute intervals if needed 2
• Maximum dose: 3 tablets (6 mg) in 24 hours, not exceeding 5 tablets (10 mg) per week 2

Oral with Caffeine (Cafergot)

• Initial dose: 2 tablets (100 mg caffeine/1 mg ergotamine per tablet) at onset 3
• Follow with 1 tablet every 30 minutes as needed 3
• Maximum dose: 6 tablets per attack, 10 tablets per week 3, 1

Rectal Administration (with Caffeine)

• One suppository (2 mg ergotamine/100 mg caffeine) at onset 3
• May repeat with one additional suppository after one hour if needed 3
• Maximum dose: 2 suppositories per attack 3

Dosage Guidelines for Dihydroergotamine (DHE)

Parenteral Administration

• Initial dose: 0.5-1.0 mg IV or IM 3, 4
• May repeat hourly as needed 3
• Maximum dose: 3 mg IM or 2 mg IV per day, not exceeding 6 mg per week 3, 4

Intranasal Administration

• Initial dose: One 0.5 mg spray in each nostril 3, 4
• Follow with one spray in each nostril 15 minutes later 3
• Maximum dose: 4 sprays (2 mg) per day 3, 4

Important Administration Principles

• Early administration at the first sign of migraine provides maximum effectiveness 1, 2, 5
• Rectal administration is preferable when severe nausea/vomiting is present 6, 5
• Intranasal DHE can be administered at any time during a migraine attack, including during the aura 5
• Ergotamine should not be used for chronic daily administration 1, 2

Contraindications

• Concurrent use of triptans (must separate by at least 24 hours) 3, 4
• Pregnancy and lactation 3, 4
• Coronary artery disease or significant cardiovascular conditions 3, 4
• Uncontrolled hypertension 3, 4
• Use of MAOIs within 14-15 days 3, 4
• Renal impairment 3
• Sepsis 3
• Ergot alkaloid sensitivity 3

Adverse Effects

Common Adverse Effects

• Nausea, vomiting, dizziness 3, 4, 7
• Paresthesia and coldness of extremities 4, 7
• Muscle pain and weakness 4, 7

Serious Adverse Effects

• Ergot poisoning 3, 7
• Medication-overuse headaches 3, 4
• Peripheral vasoconstriction and digital cyanosis 3, 7
• Cardiovascular effects (tachycardia, bradycardia, arterial spasm) 3, 4

Clinical Considerations

• Ergotamine is now used less frequently due to the availability of triptans, which generally have better efficacy and safety profiles 6, 8, 9
• Ergotamine is best suited for patients with infrequent or long-duration migraine attacks 8, 9
• For perioperative management, ergotamine should be held at least 2 days prior to surgery due to risk of peripheral vasoconstriction and serotonin syndrome when combined with anesthetics 3
• DHE has advantages over ergotamine including lower incidence of nausea/vomiting, less headache recurrence, and lack of rebound headache 5, 9
• In patients with status migrainosus and frequent headache recurrence, ergotamine may still be useful 9

Monitoring and Precautions

• Monitor for signs of ergot toxicity: severe nausea, vomiting, peripheral vasoconstriction, and angina 7
• Avoid daily use to prevent medication-overuse headaches 4, 6
• Use lowest effective dose to minimize adverse effects 3
• Be vigilant for drug interactions, particularly with medications that affect serotonin levels 3