Dihydroergotamine
MIGRANAL
Pronunciation: dye-hye-droe-er-GOT-a-meen
What it isErgot agonist at 5-HT1B/1D and adrenergic receptors; refractory migraine and status migrainosus.
Why this oneIts prolonged action lowers recurrence and can still work late in an attack when triptans often do not.
What limits itCoronary or peripheral vasospasm can be catastrophic; avoid near triptans and with strong CYP3A4 inhibitors.
FDA-approved for
- migraine and cluster headache
Off-label
- status migrainosus and medication-overuse headache bridging
FDA label
Read the full label on DailyMed ↗
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| Acute treatment of migraine with or without aura | Adults | 1 spray (0.5 mg) in each nostril; repeat 1 spray each nostril fifteen minutes later | 4 sprays (2 mg) per attack | 3 mg/24 h; 4 mg/7 days (safety beyond not established) |
Renal Contraindicated in severe renal impairment; mild–moderate Undefined
Hepatic Contraindicated in severe hepatic impairment; mild–moderate Undefined
No added benefit from >2 mg per attack. Not for migraine prophylaxis or hemiplegic/basilar migraine. First dose in a medically staffed setting (± ECG) if CAD risk factors with satisfactory CV evaluation.
Instructions
- Intranasal only — solution (4 mg/mL) must not be injected
- Prime pump before use (squeeze 4 times)
- Discard prepared applicator and any remaining drug after 8 hours
- Not for chronic daily use; do not exceed dosing guidelines (fibrotic complications)
Available strengths
- nasal spray 500, 725 mcg/spray
- powder 5.2 mg
- inj 1 mg/mL
Contraindications
- Potent CYP3A4 inhibitors (ritonavir, nelfinavir, indinavir, erythromycin, clarithromycin, troleandomycin, ketoconazole, itraconazole)
- Ischemic heart disease (angina, prior MI, silent ischemia) or coronary vasospasm incl. Prinzmetal's angina
- Uncontrolled hypertension
- 5-HT1 agonists (e.g., sumatriptan), ergotamine-containing/ergot-type drugs, or methysergide within 24 hours
- Hemiplegic or basilar migraine
- Peripheral arterial disease
- Sepsis
- Following vascular surgery
- Severe hepatic or renal impairment
- Concomitant peripheral and central vasoconstrictors (additive BP elevation)
Cautions
- CYP3A4 inhibitors (caution with less potent inhibitors)
- Fibrotic complications (pleural, retroperitoneal, cardiac valvular)
- Myocardial ischemia/infarction and other cardiac events
- Cerebrovascular events and fatalities
- Other vasospasm-related events (peripheral ischemia, gangrene)
- Increase in blood pressure
- Local nasal/throat irritation (~30%)
- Medication overuse headache
- Preterm labor — avoid in pregnancy
Adverse reactions
- Rhinitis (26%)
- Nausea (10%)
- Altered sense of taste (8%)
- Application site reaction (6%)
- Vomiting (4%)
- Dizziness (4%)
- Pharyngitis (3%)
- Somnolence (3%)
- Diarrhea (2%)
- Paresthesia (2%)
- Hot flashes (1%)
- Asthenia (1%)
Pregnancy Avoid — may cause preterm labor (from Warnings; Pregnancy subsection not in captured label text).
Cost
| Strength | #/mo | generic $/unit | CostPlus | |
|---|---|---|---|---|
| 500 mcg/spray | nasal spray | per unit | not offered | |
| 725 mcg/spray | nasal spray | per unit | not offered |
Generic entry2003
⚠ BOXED WARNING
- Serious peripheral and cerebral ischemia with CYP3A4 inhibitors
Classes and tags
Clinical profile
Legacy pregnancy categoryUnknown / historical label unavailable
Defining liabilityAgent-specific vascular, serotonergic or hepatic risks; acute overdose is usually limited outside ergot or cardiovascular agents.