Migraine Headache — Dihydroergotamine Protocol (DHE) — Clinical Pathway: Inpatient

Migraine Headache Clinical Pathway — Inpatient

Dihydroergotamine Protocol (DHE)

Age, Years Starting Dose Dose Titration Maximum Dose
6 – < 10
OR 25 kg		 0.1 mg If tolerated, increase by 0.1 mg every 8 hours until maximum dose or side effects occur 0.5 mg IV every 8 hours
≥ 10 – 12 0.2 mg If tolerated, increase by 0.2 mg every 8 hours until maximum dose or side effects occur 1 mg IV every 8 hours
≥ 12 0.25 mg If tolerated, increase by 0.25 mg every 8 hours until maximum dose or side effects occur 1 mg IV every 8 hours

Patients who have previously received DHE may start at 50% of previously maximally tolerated dose for one dose and then, if tolerated, increase to previously maximally tolerated dose

Continue DHE for at least 5 doses and up to 20 doses; if HA relief is achieved, give one additional dose

Complete any needed imaging prior to starting DHE

Please use intranasal DHE only if IV DHE is unavailable, or if the patient does not have IV access

Potential Medication Interactions with DHE

  • Triptans — DHE should not be given within 24 hrs of any triptan medication
  • Serotonin-modulating medications (including SSRIs, TCAs) — OK to continue these medications with DHE, but monitor for signs of serotonin syndrome
  • Beta-blockers — Hold beta-blockers while patient is receiving DHE
  • Midodrine — OK to continue, but monitor closely for blood pressure changes and worsening orthostatic intolerance. If patient is hypertensive, hold midodrine while giving DHE and for 2 days afterwards. If patient has worsened orthostatic intolerance, consider stopping DHE.

Insufficient Improvement after DHE

Insufficient improvement after 3 doses
  • Discuss nerve block with patient/family while continuing DHE
  • Consider adding one/both of the following for at least 2 doses for synergy with DHE:
    • Valproic Acid
    • Magnesium Sulfate
Insufficient improvement after 5 doses
  • Consider trial dose of Levetiracetam

Managing DHE Side Effects

Nausea/Vomiting
  • 1st Line: Premedicate with Metoclopramide
    0.1-0.2 mg/kg/dose (Max < 12 yrs: 10 mg, ≥ 12 yrs: 20 mg)
  • 2nd Line: Ondansetron 0.1 mg/kg (Max 4 mg) q 8 hr PRN IV/PO
    (especially if need to stop Metoclopramide)
  • 3rd Line: Diphenhydramine 1 mg/kg up to 25 mg q 8 hr PRN IV/PO
  • 4th Line: Lorazepam 0.02-0.04 mg/kg/dose q 6 hr PRN IV/PO
  • If significant nausea occurs with the first dose, decrease the dose by 50% and advance as tolerated.
Worsened Headache
  • Reduce dose of DHE to previously tolerated dose and advance as tolerated. If headache worsens significantly with the first dose, decrease the dose by 50% and advance as tolerated.
Muscle Cramping
  • PRN Lorazepam or Diazepam, consider premed before future doses.
  • Reduce dose of DHE to the previously tolerated dose and advance as tolerated. If side effect occurs with the first dose, decrease the dose by 50% and advance as tolerated. Consider acute treatment of throat tightness or muscle spasm with a benzodiazepine and then premedicating future doses of DHE with an oral benzodiazepine 30 minutes prior to DHE.
Chest Pain
  • Check EKG immediately and repeat in 6 hours. If all labs are normal, consider restarting DHE at previously tolerated dose and advance as tolerated. If side effect occurs with the first dose, decrease the dose by 50% and advance as tolerated.
  • If chest pain occurs, EKGs should be checked daily. DHE should be stopped if chest pain continues despite lower dose or if EKG shows signs of ischemia.
Vasospasm
  • Heat packs PRN, stop infusion if severe
Ergotism, DVT
  • Rare. Stop infusion/Discontinue DHE
Suggestions for Management of Adverse Effects