Injectable or Nasal Dihydroergotamine (DHE) for Migraines

When It's Used, How It Works, and Possible Side Effects

In This Article

Dihydroergotamine (DHE) is a prescription medication available in injectable and nasal forms that is used to relieve acute migraine attacks. It is among the most effective migraine treatments and considered safe for most, though not all, people. If your doctor has given you a prescription for DHE, it's worth learning more about it, including how it works and how to recognize its side effects.

how DHE relieves migraine
Illustration by JR Bee, Verywell

Indications

DHE is used for the treatment of moderate and severe migraine attacks. It does not prevent migraines and it is not intended to be taken on a regular basis.

While you can take it on your own if you have a prescription, DHE is fast acting, so it is commonly used in the emergency room for rapid migraine relief (such as in the treatment of status migrainosus). You may also receive it in an urgent care setting.

DHE can be particularly effective in treating menstrual migraines, and your doctor might consider it to be a good option for you if you experience severe nausea or vomiting with your migraines (of any type) because the drug is not taken by mouth.

DHE has a lower risk of inducing medication overuse headaches (a.k.a. rebound or medication withdrawal headaches) than other migraine medications, so it may also be recommended for you if you are prone to them.

The drug is not used to treat non-migraine headaches like tension headaches

How It Works

DHE has several actions on the body, and the migraine-relieving effect may be the result of more than one of them. This medication generally relieves the pain, nausea, and other symptoms of a migraine.

Vasoconstriction, which is narrowing of the blood vessels, is the most recognized effect of DHE, and the most closely associated with migraine relief. Migraines are believed to involve vasodilation (widening of the blood vessels) in the brain, and counteracting this effect commonly relieves related pain, at least temporarily.

The physiological mechanisms that cause DHE to have its effect on the body are that it:

  • Inhibits calcitonin gene-related peptide (CGRP): CGRP triggers inflammation, which may contribute to migraines.
  • Binds to serotonin receptors, which modulate pain and mood
  • Binds to dopamine receptors, which can inhibit CRGP release and induce vasoconstriction
  • Binds to adrenergic receptors, which induces vasoconstriction

Formulations

There are two different forms of DHE that your doctor will consider:

  • Migranal, which is administered intranasally (through the nose)
  • D.H.E 45, which is injected intramuscularly (IM into the muscle) or intravenously (IV into a vein)

This medication is not well absorbed orally (by mouth), so pill forms are not readily available in the United States.

Use

If you are given a prescription for nasal or injectable DHE, your doctor's office can provide you with instructions on how to use the medication on your own.

You can use DHE before your migraine begins, during the prodromal phase, or during the migraine attack itself. Some people notice that taking it during the prodromal phase can prevent a migraine from progressing, whereas others note that the medication wears off when taken too soon.

The best strategy is to take DHE as soon as you sense that you will have a migraine and to discuss your response to the medication with your doctor as you decide on the best timing for you.

Side Effects

It is important to seek medical attention if you experience any of the following symptoms within a few days of using DHE:

  • 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
  • Speeding or slowing of your heart rate
  • Swelling or itching
  • Dizziness
  • Trouble breathing
  • A worsening headache

Contraindications

While it is relatively safe, DHE is not for everyone.

If you have had an allergic reaction to ergotamines (e.g., Cafergot, Migergot), then DHE is not safe for you; the two drugs are very similar.

You cannot use DHE if you are pregnant or breastfeeding. DHE is also contraindicated if you have certain medical conditions, including:

  • Heart disease
  • High blood pressure
  • A history of stroke
  • Hemiplegic or basilar migraine
  • Peripheral vascular disease
  • Impaired liver or kidney function

Interactions

It's important to tell your doctor all of the medications you are taking, including over-the-counter supplements and vitamins. Some medications, particularly those that induce vasoconstriction, cannot be used with DHE.

If you are filling a prescription for DHE, check with your doctor or pharmacist to be sure that it does not interact with any of your other medications or supplements.

Be particularly attentive if you use any triptans for your migraines, as you cannot take DHE within 24 hours of taking one of these drugs, as they are also vasoconstrictors.

A Word From Verywell

DHE is often considered second-line therapy for migraines because it does not come in an easy-to-use pill form. If you and your doctor decide that DHE is the right medication for you, it is recommended that you become familiar with the side effects so that you can recognize them and get medical attention in a timely manner if you develop any.

Work with your doctor to create a healthy, multi-faceted approach to managing and preventing your migraines. Finding the right routine for your migraine care will go a long way in improving your quality of life.

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