What is the recommended dosing for Cafergot (ergotamine and caffeine) for migraine headaches?

Cafergot Dosing for Acute Migraine Treatment

For Cafergot (ergotamine 1 mg + caffeine 100 mg combination), take 2 tablets at the first sign of migraine, then 1 tablet every 30 minutes as needed, with a maximum of 6 tablets per attack and no more than 10 mg ergotamine per week. 1

Initial Dosing Strategy

• Start treatment at the earliest sign of migraine to maximize effectiveness, as early administration significantly improves efficacy 2
• Take 2 tablets (containing 100 mg caffeine/1 mg ergotamine each) at headache onset 1
• If headache persists, take 1 additional tablet every 30 minutes 1

Maximum Dose Limits (Critical for Safety)

Per Attack Limits:

• Maximum of 6 tablets per single migraine attack 1
• This equals 6 mg ergotamine and 600 mg caffeine total

Weekly Limits:

• No more than 10 mg ergotamine per week regardless of formulation or route 1, 3, 4
• Limit use to 2 days or fewer per week to prevent medication-overuse headache 1

Important Safety Considerations

Contraindications and Drug Interactions:

• Mandatory 24-hour separation from triptans due to increased vasospasm risk 1
• Absolutely contraindicated in cardiovascular disease, coronary artery disease, uncontrolled hypertension, and peripheral vascular disease 1
• Avoid concurrent use with CYP3A4 inhibitors (macrolide antibiotics, protease inhibitors) due to risk of ergotism 3

Signs of Ergotism (Toxicity):

• Watch for numbness or tingling in fingers and toes, muscle pain in arms and legs, chest pain, coldness and pallor of digits 3
• Early toxic symptoms include headache, nausea, vomiting, and general malaise 5
• Prolonged overuse can lead to gangrene from intense arterial vasoconstriction 3

Clinical Context and Positioning

When to Consider Cafergot:

• Ergotamine is positioned for moderate to severe migraines or mild to moderate migraines that respond poorly to NSAIDs 2
• From a modern perspective, triptans are generally preferred over ergotamine due to higher efficacy, fewer adverse effects, more predictable absorption, and lower risk of medication-overuse headache 1
• Ergotamine is most appropriate for patients with infrequent or long-duration headaches who are likely to comply with strict dosing restrictions 6

Comparative Efficacy:

• Clinical trials demonstrate that triptans (such as eletriptan 80 mg) achieve significantly higher headache response rates at 2 hours (68%) compared to Cafergot (33%) 7
• Only about one-third of migraine attacks require ergotamine treatment 5

Medication-Overuse Headache Prevention

• The weekly 10 mg limit is essential to prevent rebound headaches and ergotism 1, 4
• Patients using ergotamine indiscriminately over long periods may develop withdrawal symptoms consisting of rebound headache upon discontinuation 3
• Close monitoring of usage patterns is mandatory 2

Alternative Formulations

If oral Cafergot is ineffective or not tolerated:

• Ergotamine suppositories: 1 mg at onset, may repeat in 1 hour, maximum 2-3 suppositories per day 1
• Sublingual ergotamine: 2 mg at onset, then 2 mg every 30 minutes, maximum 3 tablets (6 mg) per 24 hours 3
• All formulations count toward the same 10 mg weekly maximum 1