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Dihydroergotamine (DHE)

In the pediatric patient diagnosed with a refractory migraine, what is the efficacy of DHE IV to decrease migraine pain in the Emergency Department?

 

Plain language summary from the office of evidence based practice: Based on very low quality evidence the Migraine in the ED CPG Teams makes a conditional recommendation against the use of DHE as the first line treatment of refractory migraine in the ED. However, it may be considered if:

  • Hospital admission is anticipated

  • Triptans have not been administered in the previous 24 hours

  • Subsequent doses of DHE can be administered

The key points are:

  • Response to treatment with DHE may not be apparent until after the fifth dose and it is dosed every 8 hours (Kabbouche, et al., 2009)

  • DHE cannot be given if the patient has received triptans with the previous 24 hours (Lexi-Comp, 2016)

Dose:   Dihydroergotamine-

IV: 1mG, repeat 8 hours, improvement usually seen after the fifth dose
IM/SC: 0.5- 1mG, repeat hourly if needed (max 3mG/day)
Nasal: 0.5mG each nostril Q15 min (max 3mG/day)

See Appendix D for the full Critically Appraised Topic (CAT).

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.