dihydroergotamine

Absorption: Rapidly absorbed following IM and subcut administration and 32% absorbed from nasal mucosa.

Distribution: Unknown.

Protein Binding: 90%.

Metabolism/Excretion: Highly metabolized (90%) by the liver. Some metabolites are active.

Half-life: 10 hours.

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Peripheral vascular disease
Ischemic heart disease
Uncontrolled hypertension
Severe renal or liver disease
Malnutrition
Known alcohol intolerance (injection only)
Concurrent use of CYP3A4 enzyme inhibitors (macrolide anti-infectives and protease inhibitors).
OB: Pregnancy (may cause fetal harm)
Lactation: Lactation.

Use Cautiously in:

Illnesses associated with peripheral vascular pathology such as diabetes mellitus
Concurrent administration of other vasoconstricting agents
Pedi: Children <6 yr (safety and effectiveness not established).

Adv. Reactions/Side Effects ⬆ ⬇

CV: MYOCARDIAL INFARCTION, hypertension, angina pectoris, arterial spasm, intermittent claudication.

EENT: rhinitis.

GI: abdominal pain, nausea, vomiting, altered taste, diarrhea, polydipsia.

MS: extremity stiffness, muscle pain, stiff neck, stiff shoulders.

Neuro: leg weakness, numbness or tingling in fingers or toes , dizziness.

Misc: fatigue.

Interactions ⬆ ⬇

Drug-Drug:

CYP3A4 enzyme inhibitors, including macrolides and protease inhibitors may produce serious, life-threatening peripheral ischemia; concurrent use contraindicated.
Concurrent use with beta blockers, oral contraceptives, or nicotine (heavy smoking) may ↑ risk of peripheral vasoconstriction.
Antagonizes the antianginal effects of nitrates.
Concurrent use with vasoconstrictors may have ↑ effects; avoid concurrent use.
Concurrent use with sumatriptan may result in prolonged vasoconstriction; allow 24 hr between use.

Route/Dosage ⬆ ⬇

IM, SC (Adults): 1 mg; may repeat in 1 hr to a total of 3 mg (not to exceed 3 mg/day or 6 mg/wk).
IM, SC (Children 6 yr): 0.5 mg; may be repeated in 1 hr.
IV (Adults): 0.5 mg; may repeat in 1 hr (not to exceed 2 mg/day or 6 mg/wk). For chronic intractable headache, 0.5–1 mg every 8 hr may be given until relief (not to exceed 6 mg/wk).
IV (Children 6 yr): 0.25 mg; may be repeated in 1 hr.
IV (Children 12–16 yr): Severe, acute migraine — 0.25–0.5 mg; 1–2 more doses may be given every 20 min.
IV (Children 9–12 yr): Severe, acute migraine — 0.2 mg; 1–2 more doses may be given every 20 min.
IV (Children 6–9 yr): Severe, acute migraine — 0.1–0.15 mg; 1–2 more doses may be given every 20 min.
Intranasal (Adults): 1 spray (0.5 mg) in each nostril, repeat after 15 min (2 mg total dose); not to exceed 3 mg/24 hr or 4 mg/wk.

Implementation ⬆ ⬇

Administer as soon as patient reports prodromal symptoms or headache.
Prime pump 4 times before use. Once the nasal spray applicator has been prepared, it should be discarded with any remaining drug in opened vial after 8 hrs.

IV Administration:

IV Push: Dihydroergotamine may be administered undiluted.
Rate: Administer each dose over 1 min.

US Brand Names ⬆ ⬇

Classifications ⬆ ⬇

Therapeutic Classification: vascular headache suppressants

Pharmacologic Classification: ergot alkaloids

Availability ⬆ ⬇

(Generic available)

Nasal spray: 4 mg/mL;
Solution for injection: 1 mg/mL (contains alcohol);

Time/Action Profile ⬆ ⬇

(relief of headache)

ROUTE	ONSET	PEAK	DURATION
Nasal	within 30 min	unknown	unknown
IM, subcut	15–30 min	15 min–2 hr	8 hr
IV	<5 min	15 min–2 hr	8 hr

Assessment ⬆ ⬇

Assess frequency, location, duration, and characteristics (pain, nausea, vomiting, visual disturbances) of chronic headaches. During acute attack, assess type, location, and intensity of pain before and 60 min after administration.
Monitor BP and peripheral pulses periodically during therapy. Report any increases in BP.
Assess for signs of ergotism (cold, numb fingers and toes; nausea; vomiting; headache; muscle pain; weakness).
Assess for nausea and vomiting. Ergotamine stimulates the chemoreceptor trigger zone. For adults, metoclopramide 10 mg IV may be administered 3–5 min before administration of dihydroergotamine IV. In children, metoclopramide or a phenothiazine antiemetic may be given orally as prophylaxis 1 hr before administration of dihydroergotamine IV. Oral administration may decrease risk of extrapyramidal and other side effects encountered with IV administration.

Toxicity and Overdose:

Toxicity is manifested by severe ergotism (chest pain, abdominal pain, persistent paresthesia in the extremities) and gangrene. Vasodilators, dextran, or heparin may be ordered to improve circulation.

Pot. Nursing Diagnoses ⬆ ⬇

Acute pain (Indications).
Risk for injury (Side Effects).

Patient/Family Teaching ⬆ ⬇

Instruct patient to use dihydroergotamine at the first sign of an impending headache and not to exceed the maximum dose prescribed.
- Encourage patient to rest in a quiet, dark room after taking ergotamine.
- Review symptoms of toxicity. Instruct patient to report these promptly.
- Caution patient not to smoke and to avoid exposure to cold; these vasoconstrictors may further impair peripheral circulation.
- May cause dizziness. Caution patient to avoid driving and other activities requiring alertness until response to the drug is known.
- Advise patient to avoid alcohol, which may precipitate vascular headaches.
- Rep: May be teratogenic. Advise females of reproductive potential avoid dihydroergotamine use during pregnancy and breastfeeding and to notify health care professional if pregnancy is planned or suspected or if breastfeeding.
IM, SC: Inject at the first sign of a headache and repeat at 1-hr intervals up to 3 doses. Once minimal effective dose is determined, adjust dose for subsequent attacks.
Intranasal: Instruct patient in proper use of nasal spray. Prime nasal sprayer 4 times before dose. Administer 1 spray to each nostril followed in 15 min by an additional spray in each nostril for a total of 4 sprays. Do not tilt head or sniff following spray. Do not use more than amount instructed. Discard ampule within 8 hr of opening. Do not refrigerate. Assembly may be used for 4 treatments; then discard.
- Advise patient not to use Migranal to prevent a headache if there are no symptoms or if headache is different from typical migraine.
- Instruct patient to notify health care professional if numbness or tingling in fingers or toes; pain, tightness, or discomfort in chest; muscle pain or cramps in arms or legs; weakness in legs; temporary speeding or slowing of heart rate; or swelling or itching occurs.

Evaluation/Desired Outcomes ⬆ ⬇

Relief of pain from vascular headaches.

Code ⬆

NDC Code^*

0143- West-Ward Pharmaceuticals Corp
0143-9273- Dihydroergotamine Mesylate 0143-9273-10- 10 AMPULE in 1 CARTON (0143-9273-10) > 1 mL in 1 AMPULE (0143-9273-01)

0187- Bausch Health US, LLC
0187-0245- Migranal 0187-0245-03- 8 VIAL in 1 KIT (0187-0245-03) > 1 mL in 1 VIAL

0187- Bausch Health US, LLC
0187-0245- Migranal 0187-0245-04- 1 VIAL in 1 KIT (0187-0245-04) > 1 mL in 1 VIAL

0574- Paddock Laboratories, LLC
0574-0850- Dihydroergotamine Mesylate 0574-0850-05- 5 AMPULE in 1 CARTON (0574-0850-05) > 1 mL in 1 AMPULE

0574- Paddock Laboratories, LLC
0574-0850- Dihydroergotamine Mesylate 0574-0850-10- 10 AMPULE in 1 CARTON (0574-0850-10) > 1 mL in 1 AMPULE

25021- Sagent Pharmaceuticals
25021-609- dihydroergotamine mesylate 25021-609-01- 5 VIAL in 1 CARTON (25021-609-01) > 1 mL in 1 VIAL

25021- Sagent Pharmaceuticals
25021-609- dihydroergotamine mesylate 25021-609-02- 10 VIAL in 1 CARTON (25021-609-02) > 1 mL in 1 VIAL

66490- Bausch Health US, LLC
66490-041- D.H.E. 45 66490-041-01- 10 AMPULE in 1 CARTON (66490-041-01) > 1 mL in 1 AMPULE

68682- Oceanside Pharmaceuticals
68682-357- Dihydroergotamine Mesylate 68682-357-10- 8 VIAL in 1 KIT (68682-357-10) > 1 mL in 1 VIAL

70529- IT3 Medical LLC
70529-030- Dromelate 70529-030-01- 1 AMPULE in 1 PACKAGE (70529-030-01) > 1 mL in 1 AMPULE

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Pronunciation ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇