How is ergotamine administered for migraine headaches?

Ergotamine Administration for Migraine Headaches

Ergotamine should be administered at 1-2 mg orally (or sublingually) at the first sign of migraine, repeated every 30-60 minutes as needed, with a strict 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, 2

Route-Specific Administration

Oral/Sublingual Administration

• Place one 2 mg sublingual tablet under the tongue at the earliest sign of migraine attack 2
• Repeat dosing: Take another tablet at 30-minute intervals if needed 2
• Maximum: 3 tablets (6 mg) per 24-hour period 2
• Weekly limit: 5 tablets (10 mg) maximum per week 2, 3

Oral Tablets (Ergotamine + Caffeine Combination)

• Initial dose: 2 tablets (each containing 1 mg ergotamine + 100 mg caffeine) at migraine onset 1
• Repeat dosing: 1 tablet every 30 minutes as needed 1, 4
• Maximum: 6 tablets per attack, 10 tablets per week 1, 4

Rectal Suppository

• Initial dose: 1 mg suppository at onset of migraine 1
• Repeat dosing: May repeat in 1 hour if needed 1
• Maximum: 2-3 suppositories per day 1, 5
• Rectal administration is the most effective formulation, particularly for patients with severe, rapid-onset migraine accompanied by nausea and vomiting 6

Critical Timing Considerations

• Early administration is essential for maximum effectiveness—treatment must begin at the first sign of migraine 1, 2, 3
• Oral ergotamine is most appropriate for slowly evolving migraines without early nausea/vomiting 6
• Good clinical responses are associated with plasma concentrations of 0.2 ng/ml or above within one hour of administration 3

Frequency Restrictions to Prevent Medication-Overuse Headache

• Limit use to 2 days or fewer per week to prevent rebound headaches 1
• Maximum weekly dose: 10 mg regardless of route 1, 3
• Do not use for chronic daily administration 2
• Doses exceeding 10 mg per week may cause toxic symptoms including headache, nausea, vomiting, and general malaise 7

Mandatory Safety Precautions

Drug Interactions

• Never combine with triptans—maintain a mandatory 24-hour separation between ergotamine and triptan use due to severe vasospasm risk 1, 4
• Avoid concurrent use with other vasoconstrictors 2
• Contraindicated with CYP3A4 inhibitors (macrolide antibiotics, protease inhibitors) due to elevated blood levels and vasospastic reactions 5, 2
• Beta-blockers (propranolol) potentiate ergotamine's vasoconstrictive effects 2

Absolute Contraindications

• Cardiovascular disease (coronary artery disease, peripheral vascular disease) 1, 5, 4
• Uncontrolled hypertension 1, 5, 4
• Pregnancy and lactation 5, 4, 2
• Recent MAOI use (within 14-15 days) 5

Clinical Positioning

• 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
• Ergotamine is positioned for moderate to severe migraines or mild to moderate migraines that respond poorly to NSAIDs 1
• From a medical perspective, ergotamine is the drug of choice only in a limited number of migraine sufferers who have infrequent or long-duration headaches and are likely to comply with strict dosing restrictions 8
• Oral bioavailability is extremely poor (approximately 5% or less), which contributes to variable efficacy 5, 3

Warning Signs of Ergotism

Monitor patients for signs of ergotism, which manifests as intense arterial vasoconstriction producing peripheral vascular ischemia 2:

• Numbness or tingling in fingers and toes 2
• Muscle pain in arms and legs 2
• Weakness in legs 2
• Coldness and pallor of digits 2, 3
• Intermittent claudication 2
• Chest pain or cardiac rhythm changes 2