Migranal

dihydroergotamine

(dye-hye-droe-er-got-a-meen) ,

D.H.E. 45

(trade name),

Dihydroergotamine-Sandoz

(trade name),

Migranal

(trade name) Pregnancy Category: X

Indications

Action

Pharmacokinetics

Time/action profile (relief of headache)

ROUTE	ONSET	PEAK	DURATION
Nasal	within 30 min	unknown	unknown
IM, subcut	15–30 min	15 min–2 hr	8 hr
IV	<5 min	15 min–2 hr	8 hr

Contraindications/Precautions

Adverse Reactions/Side Effects

Central nervous system

• dizziness

Ear, Eye, Nose, Throat

• rhinitis (most frequent)

Cardiovascular

• myocardial infarction (life-threatening)
• hypertension (most frequent)
• angina pectoris
• arterial spasm
• intermittent claudication

Gastrointestinal

• abdominal pain (most frequent)
• nausea (most frequent)
• vomiting (most frequent)
• altered taste
• diarrhea
• polydipsia

Musculoskeletal

• extremity stiffness
• muscle pain
• stiff neck
• stiff shoulders

Neurologic

• leg weakness
• numbness or tingling in fingers or toes

Miscellaneous

• fatigue

Interactions

Drug-Drug interaction

Concurrent use of CYP 3A4 enzyme inhibitors (macrolide anti-infectives and protease inhibitors ) may produce serious, life-threatening peripheral ischemia and is contraindicated.Concurrent use with beta blockers, oral contraceptives, or nicotine (heavy smoking) may ↑ risk of peripheral vasoconstriction.Dihydroergotamine antagonizes the antianginal effects of nitrates.Concurrent use with vasoconstrictors may have ↑ effects (avoid concurrent use).Concurrent use with sumatriptan may result in prolonged vasoconstriction (allow 24 hr between use).

Route/Dosage

Availability

Nursing implications

Nursing assessment

• Assess frequency, location, duration, and characteristics (pain, nausea, vomiting, visual disturbances) of chronic headaches. During acute attack, assess type, location, and intensity of pain before and 60 min after administration.
• Monitor BP and peripheral pulses periodically during therapy. Report any increases in BP.
• Assess for signs of ergotism (cold, numb fingers and toes; nausea; vomiting; headache; muscle pain; weakness).
• Assess for nausea and vomiting. Ergotamine stimulates the chemoreceptor trigger zone. For adults, metoclopramide 10 mg IV may be administered 3–5 min before administration of dihydroergotamine IV. In children, metoclopramide or a phenothiazine antiemetic may be given orally as prophylaxis 1 hr before administration of dihydroergotamine IV. Oral administration may decrease risk of extrapyramidal and other side effects encountered with IV administration.
Toxicity is manifested by severe ergotism (chest pain, abdominal pain, persistent paresthesia in the extremities) and gangrene. Vasodilators, dextran, or heparin may be ordered to improve circulation.

Potential Nursing Diagnoses

Acute pain (Indications)
Risk for injury (Side Effects)

Implementation

• Administer as soon as patient reports prodromal symptoms or headache.

• Intravenous Administration

• pH: 3.4–4.9.
• Dihydroergotamine may be administered undiluted.
• Rate: Administer each dose over 1 min.
• Syringe Compatibility:
  • promethazine.

Patient/Family Teaching

• Instruct patient to use dihydroergotamine at the first sign of an impending headache and not to exceed the maximum dose prescribed.
  • Encourage patient to rest in a quiet, dark room after taking ergotamine.
  • Review symptoms of toxicity. Instruct patient to report these promptly.
  • Caution patient not to smoke and to avoid exposure to cold; these vasoconstrictors may further impair peripheral circulation.
  • May cause dizziness. Caution patient to avoid driving and other activities requiring alertness until response to the drug is known.
  • Advise patient to avoid alcohol, which may precipitate vascular headaches.
  • Instruct female patients to inform health care professional if they plan or suspect pregnancy. Dihydroergotamine should not be taken during pregnancy.
• Intramuscular: Subcutaneous: Inject at the first sign of a headache and repeat at 1-hr intervals up to 3 doses. Once minimal effective dose is determined, adjust dose for subsequent attacks.
• Intranasal: Instruct patient in proper use of nasal spray. Prime nasal sprayer 4 times before dose. Administer 1 spray to each nostril followed in 15 min by an additional spray in each nostril for a total of 4 sprays. Do not tilt head or sniff following spray. Do not use more than amount instructed. Discard ampule within 8 hr of opening. Do not refrigerate. Assembly may be used for 4 treatments; then discard.
  • Advise patient not to use Migranal to prevent a headache if there are no symptoms or if headache is different from typical migraine.
  • Instruct patient to notify health care professional if numbness or tingling in fingers or toes; pain, tightness, or discomfort in chest; muscle pain or cramps in arms or legs; weakness in legs; temporary speeding or slowing of heart rate; or swelling or itching occurs.

Evaluation/Desired Outcomes

• Relief of pain from vascular headaches.