Ergotamines & DHE for Migraine

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Ergotamine are old school when it comes to the treatment of migraine. My grandmother used Ergotamines for her migraines, my mother continues to exclusively use Ergotamines. When I was diagnosed twenty years ago oral Imitrex had just hit the market, and given my mother’s reaction and only being 13 it was thought best to treat me with Ergotamines.

A very specific form of Ergotamine is beginning to have a renaissance. DHE (Dihydroegotamine) has some interesting traits and has shown to have some good data when it comes to breaking status migraine, intractable migraine, and medication overuse headache.

What is Ergotamine?

Ergotamine is a a type of a fungus a byproduct of a type of fungus known as Ergot or under the genus name Claviceps. Ergot is actually poisonous to people.

Ergotism is a condition that includes symptoms such as painful seizures, muscle spasms, paresthesias, diarrhea, itching, headaches, nausea, vomiting, hallucinations, mania, psychosis, and dry gangrene.  Dry gangrene is a condition in which the blood vessels constrict or narrow severely causing weak pulses or loss of pulses and pallor or loss of skin color, peripheral sensory loss, swelling, and eventually cell death.

DHE: An Old Dog with New Tricks (ACHE.net)1

Ergotamine was chemically isolated from Ergot and was first used to treat migraine in the 1920s. Ergotamine remained in favor as it reduced the size of blood vessels and at the time it was believed that inflammation of the blood vessels in the brain is what caused migraine. We now know that blood vessel dilation/inflammation is not the cause of migraine so it is a bit of a mystery as to how Ergomatines work.

Ergotamine tablets for migraine are typically paired with caffeine to assist the delivery of the drug. Ergotamine pills have fallen out of favor since we are beginning to understand that Migraine and Caffeine have a very complex relationship.

Ergotamines also have a lot of side effects including severe nausea. So once triptans were available in pill form many people switched to triptans as their primary migraine abortive.

DHE (Dihydroergotamine)

In the 1940s DHE was created, it is a partially synthetic refined form of ergotamine. However, it is poorly absorbed by the digestive track. Treatment with DHE requires IV, shots, or nasal spray.

There are studies showing that DHE is less likely to cause Medication Overuse Headache, and that DHE is effective even if the migraine has been ongoing. So DHE is making a comeback and is being offered via infusion by most Headache clinics.

DHE has been found to be fairly effective in treating status and/or intractable migraine as well as Medication Overuse Headache. DHE is usually given with an anti-emetic to reduce nausea. In a clinic or hospital setting DHE is usually given as a 1 to 2 day infusion

In the 1990s a DHE nasal spray was released, Migrainal. However, the triptans were hitting the market at the same time and were less expensive since they could be produced in pill form. Triptans also had positive results, and fewer side effects than DHE for most people.

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