<p>Updated Evaluation of IV Dihydroergotamine (DHE) for Refractory Migraine: Patient Selection and Special Considerations</p>

Abstract

Dihydroergotamine (DHE) is an ergot alkaloid derivative of substances produced by rye fungus. Ergotamine was first used in the field of gynecology and obstetrics, then used for migraine treatment a few years later. DHE was developed as a derivative of ergotamine. DHE, when compared to ergotamine, demonstrates greater alpha-adrenergic antagonist activity, lower arterial vasoconstriction, less dopaminergic agonism, and lower emetic potential. DHE can be delivered via several routes including intravenous (IV), intramuscular (IM), subcutaneous (SC), intranasal (IN), oral, and orally inhaled (although the latter two are not available in the USA and the last remains experimental only). DHE can be used in an outpatient basis in infusion centers, emergency departments, and urgent care centers, as well as inpatient treatment for admitted patients. There are protocols for adults as well as pediatric migraine treatment. DHE and other ergot alkaloids are considered contraindicated in pregnant women as they decrease uterine blood flow and increase uterine muscle contractility predisposing to spontaneous abortion. DHE during lactation is also not recommended as it can lead to gastrointestinal distress and weakness in infants; it can also suppress milk production. Caution should be taken before administering DHE in patients with cardiovascular risk factors. DHE is an older drug with an interesting history, yet it is still clinically useful today for patients with migraine attacks not responsive to triptans, who have a greater burden from migraine, and in refractory migraine.

Observational Analysis of the Costs Associated with Acute Treatment of Breakthrough Migraine Attacks in Medicaid Patients Using Preventive Therapies

“…This analysis of prescription data for Medicaid enrollees with FFS coverage in 2020 showed that approximately 20% of migraine-specific acute therapy prescriptions were for formulations other than generic triptan tablets. This estimate is consistent with previous research in the USA [37] and England [38] as well as with a US budget impact analysis of new acute therapies May require an extra dose or rescue medication [44][45][46][47] b 1 unit per 24 h [48] c 1 unit per month [49][50][51] d 1 unit (30-min infusion) per 3 months [52] Adv Ther [39] conducted in 2019 by the Institute for Clinical and Economic Review, suggesting that 15-25% of patients with migraine may progress beyond first-line migraine-specific acute treatments. Per-unit cost estimates based on Medicaid amounts reimbursed indicated that, among migraine-specific acute therapies, intranasal DHE is the most expensive followed by injectable DHE, injectable triptans, gepants (rimegepant, ubrogepant) and lasmiditan, intranasal triptans, other oral ergotamine-based therapies, and oral triptans.…”

“… CGRP calcitonin gene-related peptide, IV intravenous, ODT orally disintegrating tablet a May require an extra dose or rescue medication [ 44 – 47 ] b 1 unit per 24 h [ 48 ] c 1 unit per month [ 49 – 51 ] d 1 unit (30-min infusion) per 3 months [ 52 ] …”

Study of the Mechanisms and Therapeutic Approaches of Migraine in Women and Pregnancy: A Literature Review

“…Several congenital defects have been linked to this drug [52]. It is also not recommended during lactation as it suppresses prolactin secretion and causes nausea/vomiting [53]. Triptans may be considered, although their vasoconstrictor properties may carry risks during pregnancy.…”

Real-world study of intranasal ketamine for use in patients with refractory chronic migraine

“…We published several retrospective cohort studies demonstrating ketamine infusion’s potential utility in managing rCM. 10-13…”

“…We published several retrospective cohort studies demonstrating ketamine infusion's potential utility in managing rCM. [10][11][12][13] However, intravenous (IV) ketamine typically requires dose titration and AE monitoring by a pain specialist in the hospital, thus limiting its use in the outpatient setting. IN ketamine, with its simple storage and convenient administration, is an attractive alternative to IV administration.…”