Is Dihydroergotamine used to treat headaches?

Dihydroergotamine for Headaches

Yes, dihydroergotamine (DHE) is an effective medication specifically indicated for the acute treatment of migraine headaches, with particularly strong evidence for severe or refractory cases. 1

FDA-Approved Indication

• DHE is FDA-approved for the acute treatment of migraine headaches with or without aura 1
• It is not intended for migraine prophylaxis or for hemiplegic or basilar migraine 1
• DHE should only be used where a clear diagnosis of migraine has been established 1

Clinical Role and Positioning

DHE functions as a second-line or rescue treatment for acute migraine attacks, particularly when first-line therapies fail or when severe presentations require more aggressive intervention. 2

When to Use DHE:

• Intranasal DHE has good evidence for efficacy and safety as monotherapy for acute migraine attacks 2
• IV/IM DHE is recommended for severe migraine attacks requiring parenteral treatment, particularly in emergency or inpatient settings 2
• DHE is particularly appropriate for status migrainosus (prolonged severe migraine), medication-overuse headache, and migraine with high recurrence rates 3
• DHE can be administered at any time during a migraine attack, including during the aura phase 4

Advantages Over Other Ergotamines:

• DHE has a lower incidence of nausea/vomiting compared to ergotamine tartrate 4
• DHE carries minimal risk of medication-overuse headache (rebound headache) 3
• DHE has very low rates of headache recurrence 3
• DHE is more appropriate for severe migraines than ergotamine tartrate 5

Available Formulations and Dosing

Intranasal DHE:

• Particularly useful for outpatients with nausea or vomiting, potentially avoiding the need for office or hospital visits 3
• Provides convenient therapy for acute migraine 4

Parenteral DHE (IV/IM):

• Initial dose: 0.5-1.0 mg 5
• Can be repeated hourly to maximum 3 mg IM or 2 mg IV per day 5
• Maximum 6 mg per week 5
• IV administration provides rapid peak plasma levels and is most effective when rapid effect is desired 4
• IM administration is effective for moderate to severe migraine with or without nausea/vomiting 4
• Patients can be trained for home self-administration of IM DHE for acute attacks 6, 7

Critical Contraindications and Warnings

Absolute Contraindications:

• Any disease affecting heart, arteries, or circulation 1
• Documented ischemic or vasospastic coronary artery disease 1
• Concurrent use of potent CYP 3A4 inhibitors (protease inhibitors, macrolide antibiotics like erythromycin, clarithromycin, troleandomycin) 5, 1
• Concurrent use of triptans 5
• Pregnancy and lactation 5, 1
• Uncontrolled hypertension 5
• Use of MAOIs within 14-15 days 5

Serious Warnings:

• Coadministration with potent CYP 3A4 inhibitors has caused rare reports of vasospasm leading to cerebral ischemia and/or ischemia of extremities 1
• Prolonged daily use can cause pleural and retroperitoneal fibrosis 1
• Rarely, prolonged daily use has been associated with cardiac valvular fibrosis 1
• DHE should not exceed dosing guidelines and should not be used for chronic daily administration 1

Cardiovascular Risk Assessment:

• For patients with CAD risk factors (hypertension, hypercholesterolemia, smoking, obesity, diabetes, strong family history, postmenopausal females, males >40 years), cardiovascular evaluation is strongly recommended before use 1
• First dose should be administered in a physician's office or medically equipped facility for at-risk patients who have not previously received DHE 1

Common Adverse Effects

• Nausea, vomiting, dizziness, weakness 5
• Muscle pains, paresthesias, coldness of extremities 5
• Serious adverse effects include increased migraine incidence, daily headaches, ergot poisoning, tachycardia, bradycardia, and arterial spasm 5

Practical Considerations

• DHE is effective in terminating severe, long-lasting headaches 3
• It has rapid onset of action 3
• Patients with more severe headaches that preclude continuation of activity have higher response rates (61%) compared to those with less severe headaches (29%) 6
• Initial response to therapy predicts continued use of the treatment protocol 6
• For intractable headache, repetitive IV DHE therapy typically renders most patients headache-free within 3 days, though this requires hospitalization 7