Dihydroergotamine IV transitional therapy and its efficacy

Dihydroergotamine IV transitional therapy and its efficacy

For those with refractory chronic migraine, 67% have headache attack freedom during treatment and 75% have headache freedom within 1 month of completion, with duration of effect of an average of 28 days. DHE has the same contraindications as triptans. 

Pretreatment is given with 4 mg of ondansetron (obtain baseline electrocardiogram risk of QT prolongation, pregnancy test as appropriate—some clinicians prefer metoclopramide 10 mg IV instead) before each dose of DHE (no triptan for 24 hours before).

Day 1: DHE 0.5 mg in 100 mL of normal saline IV over 1 hour. If well tolerated (if not tolerated, dose is not titrated up or can be decreased to a lower dose), second dose 8 hours later of 0.75 mg in 250 mL of normal saline IV over 1 hour.

Days 2 to 5: third and subsequent doses 1 mg in 250 mL of normal saline over 1 hour IV every 8 hours with the goal of a cumulative total dose of 11.25 mg (±1 mg) over 5 days. 

For moderate or severe nausea, options are an additional dose of ondansetron 4 mg IV every 8 hours as necessary or promethazine 12.5 to 25 mg IV every 12 hours.

DHE can also be given over 2 to 3 hours or the dose decreased or not escalated. Ketorolac 30 mg IV every 12 hours prn headache can be used for 3 days. 

Some clinicians use IV valproate when DHE is contraindicated or in addition to DHE (loading dose of 15 mg/kg infused over 30 minutes followed by 5 mg/kg infused over 15 minutes every 8 hours).

Sources

  1. Orr SL, Aubé M, Becker WJ, et al: Canadian Headache Society systematic review and recommendations on the treatment of migraine pain in emergency settings.
  2. Newman LC, Yugrakh MS: Menstrual migraine: treatment options. Neurol Sci 35(Suppl 1):57-60, 2014. 
  3. Singer AB, Buse DC, Seng EK: Behavioral treatments for migraine management: useful at each step of migraine care. Curr Neurol Neurosci Rep 15(4):14, 2015.
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