Ergotamine Dosing for Migraine Treatment
For acute migraine treatment, start with 1-2 mg of ergotamine orally at the first sign of headache, repeat 1 mg every hour if needed, with a maximum of 3 doses (6 mg) per 24 hours and no more than 10 mg per week. 1, 2
Oral Ergotamine Dosing
- Initial dose: 1-2 mg at headache onset 1, 2
- Repeat dosing: 1 mg every hour as needed 1, 2
- Maximum per attack: 3 doses (3-6 mg total) 1, 2
- Maximum per 24 hours: 6 mg 1
- Maximum per week: 10 mg regardless of route 1, 3
The FDA label for Ergomar® specifies no more than 2 tablets per single migraine attack and no more than 5 tablets during any 7-day period. 4
Ergotamine + Caffeine Combination (Cafergot)
- Initial dose: 2 tablets (each containing 1 mg ergotamine + 100 mg caffeine) at onset 1
- Repeat dosing: 1 tablet every 30 minutes 1
- Maximum per attack: 6 tablets 1
Rectal Suppository Dosing
- Initial dose: 1 mg suppository at onset 1
- Repeat dosing: May repeat in 1 hour if needed 1
- Maximum per day: 2-3 suppositories 1, 2
- Maximum per month: 12 suppositories 2
Rectal administration is the most effective form of ergotamine, particularly for patients with severe, rapid-onset migraine accompanied by nausea and vomiting, achieving 73% headache relief compared to 63% with rectal sumatriptan. 5, 6
Critical Timing and Frequency Restrictions
Administer at the earliest sign of migraine—delayed dosing significantly reduces efficacy. 1, 7 Ergotamine should be taken at the first sign of headache pain, as effectiveness depends critically on early administration. 7, 8
Limit use to 2 days or fewer per week to prevent medication-overuse headache. 1, 7 This restriction is essential because ergotamine has a substantially elevated risk of causing rebound headaches compared to other acute treatments. 7
Route Selection Based on Clinical Presentation
- Oral tablets: Best for slowly evolving migraine without early nausea/vomiting 5
- Rectal suppositories: Preferred for severe, rapid-onset migraine with nausea/vomiting 5
- Inhalation: Alternative for patients who cannot tolerate oral or rectal routes 9
Absolute Contraindications to Dosing
Do not administer ergotamine in the following situations:
- Concurrent triptan use—must wait 24 hours between ergotamine and triptans 1, 7
- Pregnancy and lactation due to oxytocic effects 2, 7, 4
- Cardiovascular disease including coronary artery disease, uncontrolled hypertension, peripheral vascular disease 1, 2, 7
- Concurrent use with CYP3A4 inhibitors (macrolide antibiotics, protease inhibitors) due to increased vasospasm risk 1, 4
- Concurrent beta blockers or MAOIs 2, 4
Current Clinical Positioning
Ergotamine is now considered a third-line option after failure of NSAIDs and triptans. 7 The American College of Physicians guidelines establish that ergotamine should only be considered after patients fail combination therapy of a triptan plus NSAID or acetaminophen, due to its higher risk of medication-overuse headache and inferior tolerability. 7
Triptans are generally preferred over ergotamine due to higher efficacy, fewer adverse effects, more predictable absorption, and lower risk of medication-overuse headache. 1, 8
Specific Patient Populations Where Ergotamine May Be Appropriate
- Patients with infrequent migraines who can reliably limit use 7, 8
- Patients with long-duration attacks where sustained vasoconstriction may be beneficial 7, 8
- Patients who have failed or cannot tolerate triptans 7, 8
Warning Signs of Ergotism
Patients must report immediately: numbness or tingling in fingers and toes, muscle pain in arms and legs, weakness in legs, chest pain, or coldness of extremities. 4 These signs indicate ergotism from vasoconstriction and require immediate discontinuation. 4