A New Look at an Old Medication for Migraine Headaches — Is It Worth It?
A New Look at an Old Medication for Migraine Headaches Is It Worth It?
Abstract & Commentary
By Dara Jamieson, MD, Associate Professor of Clinical Neurology, Weill Cornell Medical College. Dr. Jamieson reports she is a retained consultant for Boehringer Ingelheim, Merck, and Ortho-McNeil, and is on the speakers bureau for Boehringer Ingelheim.
Synopsis: Dihydroergotamine, in a longer 5-day intravenous protocol for refractory primary headache appears to be efficacious, but this older medication needs to be compared directly to newer migraine treatments.
Source: Nagy AJ, et al. Intravenous dihydroergotamine for inpatient management of refractory primary headaches. Neurology 2011;77:1827-1832. Epub 2011 Nov 2.
The outcome and side effects of intravenous dihydroergotamine (IV DHE) in disabling primary headache disorders was assessed as a function of dosing in 163 patients who were admitted to the National Hospital for Neurology and Neurosurgery, London, from 2003 to 2004. Their headache diagnoses were assigned according to the International Classification of Headache Disorders, 2nd edition (ICHD-II). The patients were contacted months after discharge by telephone to review their response to therapy. Patients were asked to provide an overall assessment of the therapy's benefit as mild, moderate, or excellent. Of the patients interviewed, 114 had chronic migraine, 38 had cluster headache, and 11 had new daily persistent headache (NDPH). The mean time to follow-up for the entire cohort was 11 months. Total DHE dosage ranged from 8.25 to 11.25 mg over the admission. For the patients with migraine (n = 114), 84 of 113 (74%) reported at least some subjective benefit, with half reporting moderate or excellent overall benefit. Along with DHE treatment, overuse of acute pain medications was treated. In the 114 migraine patients treated with DHE, preventive medications to decrease the frequency and severity headaches were started in 81 patients. For patients with cluster headaches, 29 (76%) felt that the DHE had been beneficial overall, with half of that group regarding it as moderately beneficial or excellent. In patients with new persistent daily headache, only those with migrainous symptoms responded and in that group the response was less robust compared with that seen in the chronic migraine cohort. Side effects noted with DHE included: nausea (94 patients causing cessation of the medication in 6 patients), leg cramps (46 patients), limb pain (26 patients), chest tightness (5 patients), diarrhea (19 patients), constipation (5 patients), and abdominal cramps (16 patients).
The authors opined that repetitive IV DHE treatments are both effective and well-tolerated for the inpatient management of medically refractory primary headache, including chronic migraine and cluster headaches. They concluded that these data support increasing the dose of DHE to 11.25 mg over 5 days, as compared to shorter courses, based on increased pain-free responses. The authors note a number of caveats, including the lack of placebo control arm, the lack of use of migraine disability tools, and the possible improvement due to the regulation of headache medicines and the inpatient environment.
Commentary
Parenteral DHE has been used for decades to treat acute primary headaches. New methods of delivery (nasal, oral inhalation) and revised protocols have led to a resurgence of interest in this highly effective medication, which has been eclipsed by new acute and preventive medications, including triptans.
The usual inpatient protocol for IV DHE in refractory migraine is 2 days. The authors reviewed data using a longer duration of treatment and advocated a 5-day intravenous protocol with a single medication, as opposed to a shorter "cocktail" approach with multiple parenteral and oral medications. However, the authors' conclusions on efficacy are based on uncontrolled, retrospective data and further verification is needed before their protocol should supplant customary treatments. The method by which the self-reported, patient satisfaction data were collected was neither specified nor validated. This longer IV DHE protocol has not been compared to the more commonly used shorter protocol or to IV valproate sodium, which has been shown to be as effective as IV DHE for refractory migraine. The use of DHE precludes the use of triptans within 24 hours, delaying DHE's use in patients who have used triptans prior to admission. The longer intravenous protocol necessitates a longer hospitalization than may be necessary to achieve pain relief, so the extra time and expense of the longer protocol need to be justified.
Dihydroergotamine, in a longer 5-day intravenous protocol for refractory primary headache appears to be efficacious, but this older medication needs to be compared directly to newer migraine treatments.Subscribe Now for Access
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