Uses
Vascular Headaches
Acute treatment of migraine attacks (with or without aura) or cluster headaches.
One of several preferred initial therapies in moderate to severe migraines or mild to moderate migraines that respond poorly to NSAIAs.
IV treatment of intractable migraines† (e.g., status migrainosus†); usually used in combination with IV antiemetic.
Not recommended for management of hemiplegic or basilar migraine or for prophylaxis or chronic daily management of migraine.
Other Uses
Used in combination with low-dose heparin therapy for prevention of postoperative DVT and pulmonary embolism; generally has been replaced by other more effective therapies (e.g., low molecular weight heparin alone, warfarin).
Dosage and Administration
General
Vascular Headaches
- Administer as soon as possible after onset of first symptoms of vascular headache.
- After administering the initial dose, patient should lie down and relax in a quiet, darkened room.
Administration
Administer by IM, IV, or sub-Q injection or by nasal inhalation using a spray pump.
Administer by nasal inhalation or by IM, sub-Q, or direct IV injection for the acute treatment of migraine; if self-administration by parenteral route is desired, sub-Q injection generally is preferred because of ease of administration.
Administer by IM, sub-Q, or direct IV injection for the acute treatment of cluster headaches; sub-Q injection generally is preferred for self-administration because of ease of administration.
Administer by direct IV injection or continuous IV infusion† for the acute treatment of intractable migraines in an inpatient setting.
Dihydroergotamine preparations are not recommended for prolonged daily use.
Intranasal Administration
Nasal solution intended for topical intranasal use only, and must not be injected.
Prior to initial use, assemble and fully prime the spray pump (i.e., spray 4 times). Consult the manufacturer’s patient instructions for information on assembly, priming, and use of the nasal spray pump.
Spray once in each nostril; wait 15 minutes and spray once again in each nostril. Do not tilt head back or inhale through nose while administering the drug.
Discard nasal spray applicator (with any remaining drug in opened ampul) 8 hours after assembly.
IV Administration
For solution and drug compatibility information, see Compatibility under Stability.
To minimize adverse local effects, some clinicians suggest flushing the IV line or port with 10–20 mL of sodium chloride 0.45 or 0.9% prior to administering the drug. Do not mix with buffers (e.g., sodium bicarbonate, sodium acetate) to minimize local adverse effects (see Compatibility under Stability).
Dilution
For continuous IV infusion†, add 3 mg of dihydroergotamine mesylate in 1 L of sodium chloride 0.9%, resulting in a final concentration of 3 mcg/mL.
Rate of Administration
May administer undiluted by direct IV injection over 1–2 minutes.
Has been administered by continuous IV infusion† as a 3-mcg/mL solution at a rate of 126 mcg (42 mL) per hour.
Sub-Q Administration
Administer sub-Q into the middle of thigh after aspiration (to guard against accidental intravascular injection).
To minimize adverse local effects, some clinicians suggest diluting usual sub-Q dose (1 mg) with 1 mL of sodium chloride 0.9%. Do not mix with buffers (e.g., sodium bicarbonate, sodium acetate) to minimize local adverse effects (see Compatibility under Stability).
Dosage
Available as dihydroergotamine mesylate; dosage expressed in terms of the salt.
Adults
Vascular Headaches
Migraine
Intranasal
0.5 mg (1 spray) in each nostril (1 mg total) initially; repeat 15 minutes later for a total dose of 2 mg. Higher dosages provide no additional benefit.
IV
1 mg by direct IV injection initially, followed by 1 mg at 1-hour intervals until the attack has abated or a total of 2 mg has been given in a 24-hour period.
Alternatively, 3 mg has been administered by continuous IV infusion† over 24 hours for the treatment of intractable migraines.
IM
1 mg initially, followed by 1 mg at 1-hour intervals until the attack has abated or a total of 3 mg has been given in a 24-hour period.
Sub-Q
1 mg initially, followed by 1 mg at 1-hour intervals until the attack has abated or a total of 3 mg has been given in a 24-hour period.
Cluster Headaches
IV
1 mg initially, followed by 1 mg at 1-hour intervals until the attack has abated or a total of 2 mg has been given in a 24-hour period.
IM
1 mg initially, followed by 1 mg at 1-hour intervals until the attack has abated or a total of 3 mg has been given in a 24-hour period.
Sub-Q
1 mg initially, followed by 1 mg at 1-hour intervals until the attack has abated or a total of 3 mg has been given in a 24-hour period.
Prescribing Limits
Adults
Vascular Headaches
Intranasal
Safety of >3 mg in any 24-hour period and >4 mg in any 7-day period has not been established.
IV
Maximum 2 mg in any 24-hour period.
Maximum total weekly dosage: 6 mg.
IM
Maximum 3 mg in any 24-hour period.
Maximum total weekly dosage: 6 mg.
Sub-Q
Maximum 3 mg in any 24-hour period.
Maximum total weekly dosage: 6 mg.
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