• Intranasal, IV: Acute treatment of migraine headaches with or without aura.
• IV: Acute treatment of cluster headache episodes.

Contraindicated in:

• Hypersensitivity
• Peripheral arterial disease
• Ischemic heart disease or Prinzmetal's angina
• Uncontrolled hypertension
• Sepsis
• Following vascular surgery
• Severe hepatic impairment
• Severe renal impairment
• Malnutrition
• Known alcohol intolerance (injection only)
• Concurrent use of strong CYP3A4 enzyme inhibitors
• Use of other ergot-type medications or triptans with the previous 24 hr
• Concurrent use of other vasoconstrictor medications
• OB: Pregnancy (may cause preterm labor)
• Lactation: Lactation.

Use Cautiously in:

• Risk factors for ischemic heart disease (hypertension, hypercholesterolemia, smoker, obesity, diabetes, family history, postmenopausal females, or males >40 yr)
• Pedi: Safety and effectiveness not established in children.

CV: hypertension, angina pectoris, coronary artery vasospasm, intermittent claudication, MI, VENTRICULAR ARRHYTHMIA.

EENT: nasopharyngitis, rhinitis, altered smell, ear discomfort, epistaxis, nasal discomfort, pharyngitis, rhinorrhea, sinusitis.

GI: abdominal pain, nausea, diarrhea, vomiting, colonic ischemia, polydipsia.

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

Neuro: dizziness, dysgeusia, fatigue, headache, INTRACRANIAL HEMORRHAGE, leg weakness, numbness or tingling in fingers or toes, sedation, STROKE.

Resp: pleural fibrosis.

Drug-Drug:

• Strong CYP3A4 inhibitors, including clarithromycin, erythromycin, itraconazole, ketoconazole, and protease inhibitors may produce serious, life-threatening peripheral ischemia; concurrent use contraindicated.
• Concurrent use with vasoconstrictors may significantly ↑ BP; concurrent use contraindicated.
• Concurrent use with triptans or other ergot-type medications may result in prolonged vasoconstriction; allow 24 hr between use; 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.

(Generic available)

• Nasal spray: 0.5 mg/spray (Migranal); 0.725 mg/spray (Trudhesa);
• Solution for injection: 1 mg/mL (contains alcohol);

• 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).
• 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).
• Intranasal (Adults): Migranal: 1 spray (0.5 mg) in each nostril, repeat after 15 min (2 mg total dose or 4 sprays); not to exceed 3 mg (3 doses or 6 sprays)/24 hr or 4 mg (4 doses or 8 sprays)/wk. Trudhesa: 1 spray (0.725 mg) in each nostril; may repeat, if needed, after a minimum of 1 hr; not to exceed 2.9 mg (2 doses or 4 sprays)/24 hr or 4.35 mg (3 doses or 6 sprays)/wk.

D.H.E. 45, Migranal, Trudhesa

• Vasoconstriction of dilated blood vessels by stimulating alpha-adrenergic and serotonergic (5-HT) receptors.
• Larger doses may produce alpha-adrenergic blockade and vasodilation.

• Resolution of migraine or cluster headache episodes.

Therapeutic Classification: vascular headache suppressants

Pharmacologic Classification: ergot alkaloids

Absorption: Rapidly absorbed following IM and SUBQ administration and 32% absorbed from nasal mucosa. IV administration results in complete bioavailability.

Distribution: Unknown.

Protein Binding: 90%.

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

Half-life: 10 hours.

(relief of headache)

• 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 take dihydroergotamine within 24 hr of other vascular headache suppressants.
  • 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 cause fetal harm. Advise females of reproductive potential avoid dihydroergotamine use during pregnancy and breastfeeding during and for 3 days after last dose. Instruct patient to notify health care professional if pregnancy is planned or suspected or if breastfeeding. May cause preterm labor.
• 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, may lead to overuse headache. 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.

dye-hye-droe-er-GOT-a-meen

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