Can I administer dihydroergotamine for migraines in a patient who has already received 2 doses of sumatriptan (Imitrex)?

Contraindication: Do Not Give Dihydroergotamine After Sumatriptan

No, you cannot administer dihydroergotamine to a patient who has already received sumatriptan within the past 24 hours—this is an absolute contraindication. 1

Critical Timing Requirement

• A mandatory 24-hour washout period must elapse between the last dose of sumatriptan and administration of dihydroergotamine (DHE). 2, 1
• The FDA drug label explicitly states that "dihydroergotamine mesylate nasal spray, 5-HT1 agonists (e.g., sumatriptan), ergotamine-containing or ergot-type medications or methysergide should not be used within 24 hours of each other." 1
• This contraindication applies regardless of the route of DHE administration (IV, IM, SC, or intranasal). 1

Mechanism of Risk

• Both sumatriptan and DHE cause vasoconstriction through serotonin receptor mechanisms, creating additive vasoconstrictive effects when used together. 3
• Combined use can result in severe vasospasm leading to cerebral ischemia and/or ischemia of the extremities. 1
• The risk of coronary vasospasm, cardiac events (including angina, myocardial infarction, ventricular arrhythmias), and adverse cerebrovascular events is significantly elevated. 2, 1

Clinical Management Algorithm

If the patient has taken 2 doses of sumatriptan:

1. Document the exact timing of the last sumatriptan dose 1

2. If less than 24 hours have elapsed: DHE is absolutely contraindicated—consider alternative non-vasoconstrictive rescue medications such as:

   • Parenteral NSAIDs (ketorolac) 2
   • Prochlorperazine for both pain relief and nausea 2
   • Metoclopramide as adjunctive therapy 2
   • Systemic steroids for status migrainosus 2

3. If 24 hours or more have elapsed: DHE may be safely administered 1

Common Pitfall to Avoid

• Do not assume that because the patient's migraine is refractory to sumatriptan, it is acceptable to "override" this contraindication. The vasoconstrictive risk is pharmacologic, not dose-dependent on efficacy, and serious cardiovascular events have been reported with this combination. 1, 3
• The contraindication applies even if the patient received sumatriptan via different routes (oral, subcutaneous, or intranasal). 2, 1

Additional DHE Contraindications to Screen

Before administering DHE after the 24-hour window, ensure the patient does not have: 1

• Ischemic heart disease or coronary artery disease
• Uncontrolled hypertension
• Peripheral arterial disease
• Severely impaired hepatic or renal function
• Recent use of potent CYP 3A4 inhibitors (macrolides, protease inhibitors, azole antifungals)
• Pregnancy or breastfeeding