Dihydroergotamine (DHE) is an older migraine medication. Triptans have largely replaced DHE as a first-line treatment. Still, a doctor may recommend DHE if other treatments don’t relieve your symptoms.

Dihydroergotamine (DHE) was first approved for use in people with migraine in 1946. But it’s no longer a first-line treatment for the condition. Newer medications, such as triptans, have replaced it.

DHE may also be significantly more expensive than other migraine treatments. Still, DHE may offer relief when other migraine medications don’t work.

DHE is available in several forms, including:

  • nasal spray
  • injection
  • intravenous (IV)

The IV and injection methods may provide the most pain reduction. But these methods may be hard to self-administer or access in a healthcare setting.

DHE may be appropriate for you if you haven’t had success treating migraine with first-line medications, such as triptans. DHE may be of particular benefit to you if you have:

Who should not take DHE?

According to the Food and Drug Administration (FDA), you should not take DHE if you:

  • are pregnant
  • have cardiovascular disease

People taking certain medications should also avoid DHE. You shouldn’t use DHE:

  • if you take macrolide antibiotics, such as erythromycin
  • if you take protease inhibitors, a class of HIV medications
  • within 24 hours of taking another ergot alkaloid or other migraine medication

DHE infusion typically happens in a hospital, emergency department, or outpatient infusion center. The dosing and protocol will depend on the facility and your specific needs. You might stay in the hospital overnight or visit a facility for several hours on consecutive days.

Of all methods of administering DHE for migraine, IV infusion is the fastest and most effective. But it requires access to a hospital or facility with staff trained in the procedure.

The DHE home injection and IV infusion have the same bioavailability. That means both methods provide the same amount of the drug for your body to use. But unlike the IV method, you can give yourself a DHE injection at home.

A healthcare professional may give you instructions on how to administer DHE. It’s a subcutaneous injection, which means it goes under your skin and not into a muscle. It’s important to follow the instructions closely and contact a doctor if you have any questions.

To administer a DHE injection:

  1. Check the DHE ampul (vial) to make sure it’s not cracked, and the liquid isn’t cloudy or discolored.
  2. Wipe the top of the ampul with an alcohol wipe and break open the top.
  3. Tilt the ampul at a 45-degree angle and draw the liquid into a syringe.
  4. Check there are no air bubbles in the syringe.
  5. Wipe the injection site with a new alcohol wipe. The site should be in the middle of the thigh, well above the knee.
  6. Grasp a 1-inch fold of skin at the injection site.
  7. Slide the needle into the fold of skin.
  8. Gently pull back on the needle plunger to ensure no blood comes back into the syringe.
  9. Inject the medication by pushing forward on the plunger.
  10. Remove the needle and wipe the injection site with a new alcohol wipe.

The DHE nasal spray comes under the brand names Migranal and Trudhesa. Both are for use in treating a migraine attack. You cannot use them to prevent migraine episodes or to treat other types of headaches.

DHE nasal sprays don’t require a healthcare professional to administer them. You can take it at home at the onset of migraine symptoms.

But DHE in spray form has low bioavailability compared with IV infusion. Migranal has a bioavailability of 32% compared to injectable DHE. This lower value may affect how well the nasal spray works to relieve migraine compared to infusion or injection.

Migranal involves taking a single dose in the form of two sprays 15 minutes apart. You take Trudhesa in one dose, but you can take an additional dose after an hour if you don’t get relief from the first dose.

For each product, you should not use more than four sprays in a 24-hour period or six sprays in a 7-day period.


To administer a dose of Migranal:

  1. Assemble the sprayer by inserting the spray pump into the vial according to the package directions.
  2. Holding the vial upright and pointing away from your face, prime it by pumping it four times.
  3. Spray once into each nostril, with your head tilted forward. Don’t sniff the medication but allow it to absorb through the lining of the nostrils.
  4. Wait 15 minutes.
  5. Spray once more into each nostril.
  6. Dispose of the vial.

Once you prepare the vial, you can’t save the medication for another dose, even if some remains in the container.


To administer a dose of Trudhesa:

  1. Assemble the sprayer.
  2. Prime the sprayer by spraying out four pumps.
  3. Spray once into each nostril.

With Trudhesa, one spray into each nostril is a complete dose. If symptoms return, you can take a second dose using a new vial and sprayer at least 1 hour after the first dose.

You can use Trudhesa at any time during a migraine, but it may be most effective as soon as symptoms start.

DHE can cause side effects. Among the less severe side effects are:

Some of the more severe side effects that require medical attention include:

When to contact a doctor

If you experience any of the severe side effects listed above, contact a doctor right away. You should also consider contacting a doctor if mild side effects don’t go away or if you experience any other unusual problems.

Experts think DHE contracts the blood vessels that open wide during a migraine. It may also stop some processes that cause inflammation. These actions help relieve pain and migraine symptoms.

DHE binds with certain neurotransmitters, such as some receptors of serotonin, noradrenaline, and dopamine.

DHE isn’t usually a first-line treatment for migraine. That means doctors will try other options before they try DHE.

First-line treatments for mild to moderate migraine include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). Doctors may prescribe triptans for moderate to severe migraine attacks.

Second-line treatments include antiemetics and DHE in nasal spray form. Clinicians usually reserve DHE by IV or injection for migraine that’s difficult to treat.

An extensive 2021 review of studies found that all of these treatments had some effectiveness in reducing migraine pain and improving function. The study also found that calcitonin gene-related peptide antagonists and lasmiditan (Reyvow) were also effective.

All medications used to stop migraine have varying levels of availability and different mechanisms of action.

Acetaminophen and NSAIDs

Acetaminophen (Tylenol) and several NSAIDs are available over the counter without a prescription. NSAIDs include:


Triptans are prescription medicines for moderate to severe migraine. They’re significantly more expensive than NSAIDs. They work by blocking pain signals to your brain and constricting the blood vessels that open up during a migraine attack.

Triptans are available in tablets, nasal sprays, and subcutaneous injections. Examples of triptans for migraine include sumatriptan (Imitrex) and zolmitriptan (Zomig).


A doctor may prescribe an antiemetic if your migraine attack involves nausea or vomiting. While you can use it on its own, you can take it with an NSAID or triptan.

Antiemetics for migraine include metoclopramide and prochlorperazine.

Does DHE cost more than other migraine medications?

DHE can be more expensive than other migraine medications. A 2022 analysis found that ergotamines had among the highest per person per month (PPPM) costs of all migraine medications in 2020.

  • NSAIDs and non-narcotic pain relievers: $23.90
  • Triptans: $31.92
  • Ditans: $86.83
  • Gepants: $177.63
  • Ergotamines: $761.99
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Dihydroergotamine (DHE) is an older migraine medication. While doctors have largely replaced its use with triptans, DHE may still be an option if triptans don’t work. But DHE may be cost prohibitive for some people.

Talk with a doctor if your current migraine treatment isn’t working. They may look into second-line treatments, including DHE.