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