Injectable or Nasal DHE for Treating Migraines

How It's Given, and What to Watch Out For

Woman suffering from migraine
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DHE stands for dihydroergotamine and is an ergot alkaloid used to treat acute migraine attacks. Let's learn more about this migraine medication, including how it's administered and possible side effects. 

Using DHE to Treat Migraines

In addition to moderate to severe migraine attacks, DHE can be particularly effective in treating menstrual migraine, medication overuse headache, status migrainosus, or chronic migraine.

It's important to note that DHE does not prevent migraines, nor is it used to treat non-migraine headaches like tension headaches

How is DHE Administered?

DHE can be administered intranasally (through the nose) or it can be injected. D.H.E. 45 is the injectable brand name and can be given subcutaneously, intramuscularly (into the muscle) or intravenously (into a vein). Injectable DHE is commonly given in the emergency room for rapid migraine relief, especially if a person is not responding to other migraine abortive therapies, or for status migrainosus. 

Migranal is the brand name for dihydroergotamine nasal and is more commonly given in the outpatient setting — meaning prescribed at a doctor's appointment. It's interesting to note that there is an inhaled form of DHE, called Levadex, that has not been approved yet by the FDA. 

How Does DHE Work?

DHE has a number of mechanisms of action including:

  • Binding to serotonin receptors 
  • Dilating arteries
  • Binding to dopamine receptors
  • Providing anti-nausea effects

What is the Appeal of Injectable DHE?

Injectable medications bypass the gastrointestinal tract, making it appropriate for patients who suffer from nausea and vomiting as a result of a migraine.

What is the Appeal of DHE Nasal?

DHE nasal is convenient and may be a good option for people with nausea and vomiting who cannot take a pill.

Is DHE Contraindicated During Pregnancy and Breastfeeding?

Yes. Dihydroergotamine is labeled by the FDA as pregnancy category X — it's contraindicated in both pregnancy and breastfeeding mothers. 

What Should I Tell My Doctor Before Taking DHE?

It's important to tell your doctor all of the medications, including over-the-counter supplements and vitamins, you are taking. Some medications, like a type of HIV medications called protease inhibitors and macrolide antibiotics, cannot be taken in combination with DHE — as there have been reports of potentially fatal decreases in blood flow to the brain and arms and legs. In addition, DHE should not be taken with 24 hours of a triptan.

DHE is also contraindicated in people who have certain medical conditions like:

  • ischemic heart disease (e.g., history of a heart attack, angina)
  • uncontrolled high blood pressure
  • an allergy to ergot alkaloids
  • a person on a medication that raises their blood pressure through constricting blood vessels
  • hemiplegic or basilar migraine
  • peripheral arterial disease
  • sepsis — severe infection
  • after vascular surgery
  • severely impaired liver function
  • severely impaired kidney function

What are the Potential Side Effects of DHE?

Rarely, prolonged use of injectable DHE has been associated with fibrosis or thickening of parts of the lung or kidney, as well as heart valve fibrosis with other ergot alkaloid medications. Rare reports of heart attack and stroke have also been reported.

According to the FDA and manufacturer, these side effects below are rare but require immediate notification of your doctor if they occur:

  • Numbness or tingling in fingers and toes.
  • Pain, tightness, or discomfort in the chest. 
  • Muscle pain or cramps in arms and legs.
  • Weakness in legs.
  • Temporary speeding or slowing of your heart rate.
  • Swelling or itching

Some other side effects that may occur with injectable DHE include:

  • high blood pressure
  • dizziness
  • anxiety
  • trouble breathing
  • headache
  • flushing
  • diarrhea
  • rash
  • sweating

Some other side effects of nasal DHE include:

  • runny nose or congestion
  • altered sense of taste
  • application site reactions
  • dizziness
  • nausea and vomiting
  • sore throat

What Does This Mean for Me?

DHE is a beneficial migraine medication for some people. If you are prescribed D.H.E. 45 or Migranal, be sure to get trained on how to appropriately and safely use it.

In addition, be sure you understand the dosing of your DHE medication. DHE should not be used daily or for a prolonged period of time. 

Always consult your physician regarding medications.

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Article Sources
  • FDA. Novartis Pharmaceuticals Corporation. D.H.E. 45 and Migranal. 
  • Silberstein S & Kori SH. Dihydroergotamine: a review of formulation approaches for the acute treatment of migraine. CNS Drugs. 2013 May;27(5):385-94.