Dihydroergotamine Infusion Therapy

  • Jay Karri
  • Alaa Abd-Elsayed


Intravenous dihydroergotamine (DHE) is a relatively underutilized medication with a plethora of supportive clinical evidence for its use in persons with numerous headache disorders. It has been found to be effective for acute migraines, status migranosus, chronic migraines, medication overuse headaches, and cluster headaches. Given the high prevalence of these conditions and their associations to disability and significant healthcare burdens, DHE may be an appropriate medication for many people with these ailments, if reasonable and clinically appropriate. Not only has it been found to be comparable or superior to many standard of care treatments, but also DHE is relatively well tolerated with generally a generally low prevalence of severe adverse risks. However, DHE is not fully innocuous; it has an adverse effect profile that includes myocardial, cerebral, or peripheral limb ischemic or infarction. Consequently, the appropriate clinical measures must be undertaken to appropriately risk stratify DHE candidates and monitor those receiving the medication.


Dihydroergotamine Intravenous infusion Headache Migraine 


  1. 1.
    Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart WF, AMPP Advisory Group. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68(5):343–9.CrossRefGoogle Scholar
  2. 2.
    Goldstein JN, Camargo CA Jr, Pelletier AJ, Edlow JA. Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses. Cephalalgia. 2006;26(6):684–90.CrossRefGoogle Scholar
  3. 3.
    Raskin NH. Repetitive intravenous dihydroergotamine as therapy for intractable migraine. Neurology. 1986;36(7):995–7.CrossRefGoogle Scholar
  4. 4.
    Saper JR, Silberstein S, Dodick D, Rapoport A. DHE in the pharmacotherapy of migraine: potential for a larger role. Headache. 2006;46:S212–20.CrossRefGoogle Scholar
  5. 5.
    Marmura MJ, Goldberg SW. Inpatient management of migraine. Curr Neurol Neurosci Rep. 2015;15(4):13.CrossRefGoogle Scholar
  6. 6.
    Kelley NE, Tepper DE. Rescue therapy for acute migraine, part 1: triptans, dihydroergotamine, and magnesium. Headache. 2012;52(1):114–28.CrossRefGoogle Scholar
  7. 7.
    Silberstein SD, US Headache Consortium. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review) Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55(6):754–62.CrossRefGoogle Scholar
  8. 8.
    Silberstein SD. The pharmacology of ergotamine and dihydroergotamine. Headache. 1997;37:S15–25.CrossRefGoogle Scholar
  9. 9.
    Saper JR, Silberstein S. Pharmacology of dihydroergotamine and evidence for efficacy and safety in migraine. Headache. 2006;46:S171–81.CrossRefGoogle Scholar
  10. 10.
    Silberstein SD, McCrory DC. Ergotamine and dihydroergotamine: history, pharmacology, and efficacy. Headache. 2003 Feb;43(2):144–66.CrossRefGoogle Scholar
  11. 11.
    Bongard O, Bounameaux H. Severe iatrogenic ergotism: incidence and clinical importance. VASA Zeitschrift fur Gefasskrankheiten. 1991;20(2):153–6.PubMedGoogle Scholar
  12. 12.
    Bérard A, Kori S. Dihydroergotamine (DHE) use during gestation and the risk of adverse pregnancy outcomes. Headache. 2012;52(7):1085–93.CrossRefGoogle Scholar
  13. 13.
    Markowitz S, Saito K, Moskowitz MA. Neurogenically mediated plasma extravasation in dura mater: effect of ergot alkaloids: a possible mechanism of action in vascular headache. Cephalalgia. 1988;8(2):83–91.CrossRefGoogle Scholar
  14. 14.
    Olesen J, Lipton RB. Migraine classification and diagnosis. International Headache Society criteria. Neurology. 1994;44(6 Suppl 4):S6–10.PubMedGoogle Scholar
  15. 15.
    Silberstein SD. Migraine symptoms: Results of a survey of self-reported migraineurs. Headache. 1995;35(7):387–96.CrossRefGoogle Scholar
  16. 16.
    Couch JR Jr, Diamond S. Status migrainosus: causative and therapeutic aspects. Headache. 1983;23(3):94–101.CrossRefGoogle Scholar
  17. 17.
    Ziegler D, Ford R, Kriegler J, Gallagher RM, Peroutka S, Hammerstad J, Saper J, Hoffert M, Vogel B, Holtz N, DiSerio F. Dihydroergotamine nasal spray for the acute treatment of migraine. Neurology. 1994;44(3 Part 1):447.CrossRefGoogle Scholar
  18. 18.
    Blumenthal HJ, Weisz MA, Kelly KM, Mayer RL, Blonsky J. Treatment of primary headache in the emergency department. Headache. 2003;43(10):1026–31.CrossRefGoogle Scholar
  19. 19.
    Vinson DR, Hurtado TR, Vandenberg JT, Banwart L. Variations among emergency departments in the treatment of benign headache. Ann Emerg Med. 2003;41(1):90–7.CrossRefGoogle Scholar
  20. 20.
    Gupta MX, Silberstein SD, Young WB, Hopkins M, Lopez BL, Samsa GP. Less is not more: underutilization of headache medications in a university hospital emergency department. Headache. 2007 Sep;47(8):1125–33.CrossRefGoogle Scholar
  21. 21.
    Nagy AJ, Gandhi S, Bhola R, Goadsby PJ. Intravenous dihydroergotamine for inpatient management of refractory primary headaches. Neurology. 2011;77(20):1827–32. Scholar
  22. 22.
    Buse DC, Manack AN, Fanning KM, Serrano D, Reed ML, Turkel CC, Lipton RB. Chronic migraine prevalence, disability, and sociodemographic factors: results from the American Migraine Prevalence and Prevention Study. Headache. 2012 Nov;52(10):1456–70.CrossRefGoogle Scholar
  23. 23.
    Silberstein S, Tfelt-Hansen P, Dodick DW, Limmroth V, Lipton RB, Pascual J, Wang SJ, Task Force of the International Headache Society Clinical Trials Subcommittee. Guidelines for controlled trials of prophylactic treatment of chronic migraine in adults. Cephalalgia. 2008;28(5):484–95.CrossRefGoogle Scholar
  24. 24.
    Holroyd KA, Penzien DB. Pharmacological versus non-pharmacological prophylaxis of recurrent migraine headache: a meta-analytic review of clinical trials. Pain. 1990;42(1):1–3.CrossRefGoogle Scholar
  25. 25.
    Horton BT, Peters GA, Blumenthal LS. A new product in the treatment of migraine-a preliminary report. In Proceedings of the Staff Meetings of the Mayo Clinic 1945 Jan 1 (Vol. 20, No. 14, pp. 241–8). 660 Siebens BLDG Mayo Clinic, Rochester, MN 55905: Mayo Clinic Proceedings.Google Scholar
  26. 26.
    Callaham M, Raskin N. A controlled study of dihydroergotamine in the treatment of acute migraine headache. Headache. 1986;26(4):168–71.CrossRefGoogle Scholar
  27. 27.
    Silberstein SD, Silberstein JR. Chronic daily headache: long-term prognosis following inpatient treatment with repetitive IV DHE. Headache. 1992;32(9):439–45.CrossRefGoogle Scholar
  28. 28.
    Pringsheim T, Howse D. In-patient treatment of chronic daily headache using dihydroergotamine: a long-term follow-up study. Can J Neurol Sci. 1998;25(2):146–50.CrossRefGoogle Scholar
  29. 29.
    Magnoux E, Zlotnik G. Outpatient intravenous dihydroergotamine for refractory cluster headache. Headache. 2004;44(3):249–55.CrossRefGoogle Scholar
  30. 30.
    Silberstein SD, Olesen J, Bousser MG, Diener HC, Dodick D, First M, Goadsby PJ, Göbel H, Lainez MJ, Lance JW, Lipton RB. The International Classification of Headache Disorders, (ICHD-II)—-Revision of Criteria for 8.2 Medication-Overuse Headache. Cephalalgia. 2005;25(6):460–5.CrossRefGoogle Scholar
  31. 31.
    Scher AI, Stewart WF, Liberman J, Lipton RB. Prevalence of frequent headache in a population sample. Headache. 1998;38(7):497–506.CrossRefGoogle Scholar
  32. 32.
    Diener HC, Limmroth V. Medication-overuse headache: a worldwide problem. Lancet Neurol. 2004 Aug 1;3(8):475–83.CrossRefGoogle Scholar
  33. 33.
    Evers S, Marziniak M. Clinical features, pathophysiology, and treatment of medication-overuse headache. Lancet Neurol. 2010;9(4):391–401.CrossRefGoogle Scholar
  34. 34.
    Silberstein S, Saper S. In: Silberstein SD, Lipton RB, Dalessio DJ, editors. Wolff’s headache and other head pain. New York: Oxford University Press; 2001. p. 273–4.Google Scholar
  35. 35.
    Fritsche G, Eberl A, Katsarava Z, Limmroth V, Diener HC. Drug-induced headache: long-term follow-up of withdrawal therapy and persistence of drug misuse. Eur Neurol. 2001;45(4):229–35.CrossRefGoogle Scholar
  36. 36.
    Saper JR, Hamel RL, Lake AE. Medication overuse headache (MOH) is a biobehavioural disorder. Cephalalgia. 2005;25(7):545–6.CrossRefGoogle Scholar
  37. 37.
    May A. Cluster headache: pathogenesis, diagnosis, and management. Lancet. 2005;366(9488):843–55.CrossRefGoogle Scholar
  38. 38.
    Saadah HA. Abortive headache therapy in the office with intravenous dihydroergotamine plus prochlorperazine. Headache. 1992;32(3):143–6.CrossRefGoogle Scholar
  39. 39.
    Belgrade MJ, Ling LJ, Schleevogt MB, Ettinger MG, Ruiz E. Comparison of single dose meperidine, butorphanol, and dihydroergotamine in the treatment of vascular headache. Neurology. 1989;39(4):590–2.CrossRefGoogle Scholar
  40. 40.
    Redaction P. Fibrosis due to ergot derivatives: exposure to risk should be weighed up. Prescrire Int. 2002;11:186–9.Google Scholar
  41. 41.
    Pryse-Phillips WE, Dodick DW, Edmeads JG, Gawel MJ, Nelson RF, Purdy RA, Robinson G, Stirling D, Worthington I. Guidelines for the diagnosis and management of migraine in clinical practice. Can Med Assoc J. 1997;156(9):1273–87.Google Scholar
  42. 42.
    Evans RW. An update on the mangement of chronic migraine. Pract Neurol. 2013:27–32.Google Scholar
  43. 43.
    Paemeleire K, Crevits L, Goadsby PJ, Kaube H. Practical management of medication-overuse headache. Acta Neurol Belg. 2006;106(2):43–51.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Jay Karri
    • 1
  • Alaa Abd-Elsayed
    • 2
  1. 1.Department of Physical Medicine and RehabilitationBaylor College of MedicineHoustonUSA
  2. 2.Department of AnesthesiologyUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA

Personalised recommendations