Dihydroergotamine Intravenous for Adults

Who can administer

May be administered by registered competent doctor or nurse/midwife

Prescription must be initiated by consultant/registrar neurologist- as significant contraindications and interactions

Important information

  • Must be prescribed by a consultant neurologist or Registrar neurologist as significant contraindications and interactions
  • Drug name must be written in full - no abbreviations, as experience shows that attempts to do so increase the risk of serious error
  • Unlicensed medicine
  • Drug interactions - several important and serious interactions. Use interaction checker before prescribing
    • Important: should not be administered to patients who have received a triptan in the preceding 24 hours (risk of arterial vasospasms) (ref 2)

Available preparations

Dihydroergotamine (DHE) Mesylate Injection USP 1mg in 1ml (unlicensed)

Reconstitution

Already in solution for injection

Infusion fluids

Sodium chloride 0.9%

Methods of intravenous administration

Intermittent intravenous infusion (locally preferred route - off-label(ref 4))

  • Add required dose to 250mL infusion fluid and administer over one hour

Slow intravenous injection (ref 1,2)

  • Administer required dose over 1 to 2 minutes

    Dose in adults

    Migraine

    • Give 1mg at first sign of headache; repeat once after ONE hour if required.(ref 1)
    • The maximum recommended dose varies in different reference sources
      • SPC: maximum is 2mg per migraine attack
      • UpToDate and Martindale: maximum is 2 or 3mg in 24 hours and/or 6mg in 1 week

    Intractable migraine (status migrainosus; >72 hours) (ref 2)

    • Raskin protocol (off-label dosing):

      • the doses given here are a modified version of the Raskin protocol- based on local expert opinion (ref 4)
    • 1. Pre-medicate with ondansetron 4mg IV every eight hours, given at least 30 minutes before each dihydroergotamine dose or alternative anti-emetic (where not contraindicated) (ref 4)
    • 2. Give 0.5mg dihydroergotamine
    • 3. Titrate to a range of 0.2 to 1mg every 8 hours for 2 to 3 days - see Table 1 below for an example of dose titration
      • However, a maximum daily dose of 2mg should not be exceeded, without consultant input
      • Local expert opinion: max 8mg per week (ref 4)
    Table 1: Example of dose titration for intractable migraine
    Start Dose 1 0.5mg
    8 hours later Dose 2 0.7mg
    8 hours later Dose 3 0.8mg (max advised daily dose is 2mg see below)
    8 hours later Dose 4 1mg

    After completion of dose titration, subsequent doses should be administered at the maximum tolerated dose (maximum 1 mg per dose).

    A maximum of seven additional doses may be given on consultant advice.

    A total daily dose of 2 mg should not be exceeded without consultant input.

    Renal impairment (ref 2)

    • Contraindicated in severe renal impairment

    Hepatic (ref 2)

    • Contraindicated in severe hepatic dysfunction

    Monitoring

    • Refer to full prescribing information (ref 1,2). In particular monitor for signs of ergotism, serotonin syndrome and cerebral, cardiovascular or vascular ischaemia

    Storage

    Store below 250C

    References

    1: SPC "Dihydroergotamine (DHE): Prescribing Information". Sterimax Inc. Oakville. USA. Date of revision Oct 2019

    2. Uptodate "Dihydroergotamine: Drug Information. Lexicomp. Accessed May 2026

    3. Martindale, accessed via Medicinescomplete May 2026

    4: Expert opinion Dr Thomas Monahan, Consultant Neurologist. Email on file 8th, 23rd June, 2023, 21st May 2026

    Therapeutic classification

    Ergot alkaloid