Ergotamine Dosage for Migraine Treatment
For acute migraine treatment, ergotamine should be dosed at 1-2 mg orally at headache onset, repeated every hour if needed, with a maximum of 3 doses (6 mg) per 24 hours and no more than 10 mg per week to prevent ergotism and medication-overuse headache. 1
Dosing by Route of Administration
Oral Ergotamine (Sublingual Tablets)
- Initial dose: 1-2 mg at first sign of migraine 1
- Repeat dosing: 1 mg every hour as needed 1
- Maximum per attack: 3 doses (3 mg total) 1
- Maximum weekly: 10 mg to minimize toxicity 2
- FDA-approved dosing: 1 tablet at onset, maximum 2 tablets per attack, maximum 5 tablets per week 3
Rectal Ergotamine (Suppositories)
- Initial dose: 1 mg suppository at onset 1
- Repeat dosing: May repeat in 1 hour if needed 1
- Maximum per attack: 2-3 suppositories per day 1
- Maximum monthly: 12 suppositories 1
- Rectal route is most effective: Provides 73% headache relief compared to 63% with rectal sumatriptan 4, 5
Ergotamine + Caffeine Combination (Cafergot)
- Initial dose: 2 tablets (100 mg caffeine/1 mg ergotamine) at onset 1
- Repeat dosing: 1 tablet every 30 minutes 1
- Maximum per attack: 6 tablets 1
- Maximum weekly: 10 tablets 1
- Suppository form: 1 suppository (2 mg ergotamine/100 mg caffeine) at onset, may repeat in 1 hour; maximum 2 per attack 1
When to Use Ergotamine
Ergotamine is now considered second-line therapy and should be reserved for specific situations 1:
- Moderate to severe migraine that responds poorly to NSAIDs 1
- Slowly evolving migraine without early nausea/vomiting (oral route) 6
- Severe, rapid-onset migraine with nausea/vomiting (rectal route preferred) 6
- Status migrainosus or frequent headache recurrence where triptans have failed 5
Critical Safety Warnings
Absolute Contraindications
The FDA mandates avoiding ergotamine in 7, 3:
- Concurrent triptan use (must wait 24 hours between medications) 1
- Pregnancy (oxytocic effects cause uterine contractions) 7, 3
- Breastfeeding (excreted in breast milk, causes vomiting, diarrhea, unstable blood pressure in infants) 7, 3
- Cardiovascular disease: coronary artery disease, uncontrolled hypertension, peripheral vascular disease 1
- CYP3A4 inhibitors: macrolide antibiotics, protease inhibitors (risk of severe vasospasm) 7, 3
Ergotism Risk
Strict dosage limits are essential to prevent ergotism, which manifests as 1, 7, 3:
- Intense arterial vasoconstriction and peripheral vascular ischemia 7
- Numbness, tingling, coldness of extremities 1, 7
- Muscle pain in arms and legs 7, 3
- Intermittent claudication 7
- Gangrene if untreated 7, 3
Medication-Overuse Headache
- Limit use to 2 days or fewer per week to prevent rebound headaches 1
- Maximum 10 mg per week regardless of route 2
- Chronic daily use causes withdrawal headaches and increased migraine frequency 1
Comparison to Triptans
Triptans are generally preferred over ergotamine because they are 1, 4, 5:
- More effective (oral sumatriptan superior to oral ergotamine) 4, 5
- Cause fewer adverse effects 4
- Have more predictable absorption 2
- Lower risk of medication-overuse headache 1
Exception: Rectal ergotamine may be more effective than rectal triptans (73% vs 63% relief) 4, 5
Timing and Efficacy Considerations
- Administer at earliest sign of migraine for maximum effectiveness 1, 6
- Oral bioavailability is only 5% or less due to poor absorption 2
- Can be given during aura (unlike older recommendations) 6
- Plasma concentrations ≥0.2 ng/mL within 1 hour associated with good response 2
- Try for 2-3 headache episodes before abandoning therapy 1
Common Adverse Effects
Patients should report immediately 1, 7, 3:
- Nausea and vomiting (most common) 1, 2
- Numbness or tingling in fingers/toes 7, 3
- Muscle weakness, especially in legs 1, 7
- Chest pressure or pain 1
- Tachycardia or bradycardia 1