THERAPEUTICS

Brands

• Migranal, DHE-45, Dihydergot, Semprana

Generic?

• Yes

Class

• Ergot

Commonly Prescribed for

(FDA approved in bold)

• Acute migraine treatment

• Acute cluster headache treatment

• Status migrainosus

How the Drug Works

• Strong 5-HT1B/1D agonist (stronger than sumatriptan) with additional binding to α1,2-adrenergic, 5-HT1A/2A/2B/2C, D2 receptors

• In addition to vasoconstriction on meningeal vessels, its antinociceptive effect is likely due to blocking the transmission of pain signals at trigeminal nerve terminals (preventing the release of inflammatory neuropeptides) and synapses of secondorder neurons in the trigeminal nucleus caudalis and third-order neurons in the thalamus. The site of pharmacological action, whether central or peripheral, remains to be studied

How Long Until It Works

• Migraine/cluster: within 1–2 hours

If It Works

• Continue to take as needed. Patients taking acute treatment more than 2 days/week are at risk for medication-overuse headache, especially if they have migraine

If It Doesn't Work

• Treat early in the attack (before severe pain)

• Address life style issues (e.g., stress, sleep hygiene), medication use issues (e.g., compliance, overuse), and other underlying medical conditions

• Change to higher dosage, another administration route, or combination of other medications (e.g., corticosteroid, antiemetics, NSAIDs). Add preventive medication when needed

Best Augmenting Combos for Partial Response or Treatment-Resistance

• Migraine: non-steroidal anti-inflammatory drugs (NSAIDs) or antiemetics are often used to augment response

• Cluster: oxygen (high-flow)

• Status migrainosus: combine with neuroleptics, ketorolac, diphenhydramine, IV valproate, IV magnesium, hydrate, and start preventative treatment

Tests

• Monitor blood pressure – especially after IV administration

ADVERSE EFFECTS (AEs)

How the Drug Causes AEs

• Actions on serotonin receptors cause vasoconstriction, nausea

Notable AEs

• Nausea, dizziness, sedation, dysphoria, chest or throat tightness, diarrhea, abdominal cramping

• Muscle pains, coldness, pallor, and cyanosis of digits

• Hypertension, flushing

• Altered taste, rhinitis (nasal spray), injection site reaction (IM)