Utility of IV DHE

[ghost dog]

Hi All,

I was wondering what people's experience with using IV DHE has been in regards to the utility of this medication for:

1. Medication overuse headache.

2. Status migraine.

3. Chronic migraine / i.e. breaking the cycle of headache.

Specifically, using DHE in the ambulatory / outpatient setting is what I had in mind.

I practice in Canada, and thus inpatient Tx is not a possibility.

Any insight would be appreciated.

Do your clinical experiences reflect the studies?

---

Members don't see this ad.

 

[neurologist]

My experience:

Very useful for acute and status migraine. There is, in fact, an "unofficial" school of thought that holds that if IV DHE doesn't work, then it's not even a migraine.

Not helpful for chronic migraine or medication overuse HA.

I have never used it in an outpatient setting, mostly due to time constraints (usual protocol is to dose every 8 hours up to 3 times prn, which could end up being overnight if patient needs multiple doses), but if you had the right setup, I guess you could do this. Also, need to watch vitals.

 

[kutastha]

During my residency, we'd occasionally give patients a one-time dose of it in the ED with good results. Not exactly outpatient, but the idea's the same.

 

[ghost dog]

My experience:

Very useful for acute and status migraine. There is, in fact, an "unofficial" school of thought that holds that if IV DHE doesn't work, then it's not even a migraine.

Not helpful for chronic migraine or medication overuse HA.

I have never used it in an outpatient setting, mostly due to time constraints (usual protocol is to dose every 8 hours up to 3 times prn, which could end up being overnight if patient needs multiple doses), but if you had the right setup, I guess you could do this. Also, need to watch vitals.

Interesting, as the data seem to indicate that IV DHE may be helpful for MOH (chronic headache), while pt is stopping med of overuse.

I practice in Canada, and inpatient admission is next to impossible / not practical at all. Do you think the Raskin protocol is modifiable to once daily IV dosing?

The monitoring issue would not be a problem, as I have an RN / ECG / vitals set up in the clinic.

An alternative could be that of home IM DHE (i.e. between daily IV doses), as patients can do this themselves. A potential concern would be that of monitoring though, however there is lesser absorption with this route.

 

[neurologist]

Interesting, as the data seem to indicate that IV DHE may be helpful for MOH (chronic headache), while pt is stopping med of overuse.

I practice in Canada, and inpatient admission is next to impossible / not practical at all. Do you think the Raskin protocol is modifiable to once daily IV dosing?

The monitoring issue would not be a problem, as I have an RN / ECG / vitals set up in the clinic.

An alternative could be that of home IM DHE (i.e. between daily IV doses), as patients can do this themselves. A potential concern would be that of monitoring though, however there is lesser absorption with this route.

There is an injectable formulation ("DHE 45") that a patient can inject IM or SC. I tried it on a few patients a number of years ago with mixed but generally disappointing results. Similar mixed results with the nasal spray formulation. The IV route has really seemed the most effective "in my experience."

 

[ghost dog]

There is an injectable formulation ("DHE 45") that a patient can inject IM or SC. I tried it on a few patients a number of years ago with mixed but generally disappointing results. Similar mixed results with the nasal spray formulation. The IV route has really seemed the most effective "in my experience."

The problem is the bioavailability of DHE in regards to the SC and intranasal format. I'm pretty sure this is the reason for lack of clinical response.

One of the headache bigwigs did a review on this awhile back; can't remeber who. Bigal, or maybe Saper.

 

[Head]

I only use DHE for status migrainosus.

For medication overuse headache I just have them stop all pertinent meds, stress lifestyle mods like 8hrs sleep, exercise 3-5 x per week, cutting down on caffeine consumption, and tell them, "Your headaches are likely to get worse for the next 2 weeks before they start to get better". I rarely start a headache prophylactic med, because many of these (amitriptyline) don't usually kick in for 2-4 weeks anyway.

If one of my clinic patients is in status migrainosus, I have them come into the infusion clinic here and give them a cocktail of iv DHE, iv Toradol, and iv compazine. This works very well and they usually just go home once the infusion is complete. If you don't have an infusion clinic, your nurse could probably do this in an office type setting. Remember to avoid DHE in pts. with significant HTN or hx of CVA or CAD. I also wouldn't recommend giving it more than once a week at most. Most patients would just need this once in a blue moon to avoid an ER visit.

I don't use DHE for patients with chronic migraine.

 

[bustbones26]

Hi All,

I was wondering what people's experience with using IV DHE has been in regards to the utility of this medication for:

1. Medication overuse headache.

2. Status migraine.

3. Chronic migraine / i.e. breaking the cycle of headache.

Specifically, using DHE in the ambulatory / outpatient setting is what I had in mind.

I practice in Canada, and thus inpatient Tx is not a possibility.

Any insight would be appreciated.

Do your clinical experiences reflect the studies?

I have unofficially asked patients to use nasal DHE for three days, TID and this actually worked. No evidence based medicine on it, but it worked.

Also, if you can set up home infusion, you can set the patient up at home. 3mg diluted in 1000ml of saline dripped at 42ml/hr. The publication on this was intended for home based therapy, but I actually have used this protocol in the hospital to reduce confusion/nursing errors and it has worked out well.

 

[neurologist]

I have unofficially asked patients to use nasal DHE for three days, TID and this actually worked. No evidence based medicine on it, but it worked.

http://www.ncbi.nlm.nih.gov/pubmed?term=weintraub 2006 dihydroergotamine

Also, if you can set up home infusion, you can set the patient up at home. 3mg diluted in 1000ml of saline dripped at 42ml/hr. The publication on this was intended for home based therapy, but I actually have used this protocol in the hospital to reduce confusion/nursing errors and it has worked out well.

Hmm, never heard of that one. Maybe I'll try that some time.