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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
Important information
- Must be prescribed by a consultant neurologist or Registrar neurologist
- 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
- Contraindicated in many types of cardiovascular disorders, peripheral vascular disease (see ref 2)
Drug interactions
- Potent CYP3A4 inhibitors including protease inhibitors and macrolide antibiotics e.g. clarithromycin: Serious and life-threatening peripheral and cerebral ischemia (risk of vasospasm leading to cerebral ischemia and ischemia of the extremities increased). Co-administration with dihydroergotamine is contraindicated (ref 1)
- Peripheral and central vasoconstrictors or ergot alkaloids- co-administration with dihydroergotamine is contraindicated
- Serotonin agonists: do not use within 24 hours
- MAO inhibitors: do not use within 2 weeks
- Refer to full prescribing information for further information (ref 1, 2)
Available preparations
Dihydroergotamine (DHE) Mesylate Injection USP 1mg in 1ml (unlicensed) [DIN 00027243]
Reconstitution
Already in solution for injection
Infusion fluids
Sodium chloride 0.9%
Methods of intravenous administration
Intermittent intravenous infusion (ref 3,4)
- Add required dose to 100 to 250ml infusion fluid and administer over 60 minutes
Dose in adults
Migraine, cluster headache (ref 2)
- Give 1mg at first sign of headache; repeat once in ONE hour if required. Maximum is 2mg in 24 hours and/or 6mg in 1 week
Intractable migraine (status migrainosus; >72 hours)
- Raskin protocol (off-label dosing):
- 1. Pre-medicate with metoclopramide or alternative anti-emetic (where not contraindicated)
- 2. Give 0.5mg dihydroergotamine
- 3. Titrate to a range of 0.2 to 1mg every 8 hours for 2-3 days (NB this may exceed the licensed maximum doses above)
- There may be a role for using this drug for up to seven days (ref 2,5)
- Administer with/without metoclopramide or other antiemetic based on response and tolerance
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 25 C
References
1. "Dihydroergotamine (DHE): Prescribing Information". Sterimax Inc. Oakville. USA. Date of revision February 9, 2016.
2. "Dihydroergotamine: Drug Information. Lexicomp. Accessed online 4th April 2019
3. Intravenous dihydroergotamine for inpatient management of refractory primary headaches Neurology 2011;77:1827-1832
4. Injectable medicines guide London Hospitals
5. Expert opinion Dr Thomas Monahan, consultant neurologist. Email on file 17th April 2019
Therapeutic classification
Ergot alkaloid