DHE infusion for Migraine

Timothy C. Hain, MD Page last modified: November 25, 2011

Other links:

• Migraine
• migraine prevention

Overview:

Persons with intractable migraine are sometimes admitted for intravenous treatment with dhydroergotamine (DHE).  This treatment, sometimes called the "Raskin" protocol (Raskin, 1986) nearly always works at least for a few days, because it shuts off pain input circuitry.   Sometimes the relief gained from DHE enables the treaters to implement longer lasting migraine treatments such as the migraine prevention drugs reviewed above. 

The purpose of this page is to document the DHE protocol, as reported by Nagy et al (2011).

This material is abstracted from the appendix of Nagy et al. Please refer to the original for more details.

• Admission
  • discontinue medications that have effect on serotonin receptors,
  • vital signs.
• Baseline labs
  • EKG, weight, basic labs, pregnancy screen if of childbearing age, tox screen.
• Consider and educate concerning adverse effects
  • Nausea and vomiting, leg cramps, chest discomfort, others
  • Cardiovascular effects
  • Ergotism
• Contraindications
  • Peripheral vascular disease, cardiac disease, history of CVA, uncontrolled hypertension
  • Impaired liver or renal function
  • Pregnancy
• Dosing for patients older than 16 years and weighing more than 50 kg
  • Pretreat
    • ondansetron, 30 min prior to each DHE infusion
    • May also use domperidone 10-20 PO or suppository, where available
  • Intended dosing -- every 8 hours, for 5 days. May readjust dose, based on the formula:
    • Dose = intended dose * (patient weight in kg)*.014.
  • Day 1. 
    • 0.5 mg in 100 ml NS over one hour
    • If well tolerated, escalate 8 hours later to 0.75 in 250 mg NS over one hours
  • Day 2-5
    • third and subsequent doses, 1 mg in 250 mg of NS over 1 hour
    • Top dose of 11.25 mg +- 1 mg
  • Side effect management
    • For nausea, increase ondansetron
    • Add another antiemetic such as promethazine
    • Slow the infusion to over 2-3 hours
    • Reduce dose

References:

• Nagy A and others. Intravenous dihydroergotamine for inpatient management of refractory primary headaches. Neurology 2011:77:1827-1832.
• Raskin NH. Repetitive intravenous dihydroergotamine as therapy for intractable migraine. Neurology 1986:36:995-997