Ergot Alkaloids. Ergotamine tartrate and dihydroergotamine (DHE)
may be used for patients with moderate to severe migraines or for
patients that did not respond to treatment with non-specific agents.2,4
Overall, there is inconsistent evidence regarding the efficacy of
ergotamine in the treatment of migraines.2 It is supplied as an oral
and sublingual tablet, as well as a rectal suppository. The oral and
rectal forms of this medication are formulated in combination with
caffeine in order to increase absorption and analgesic activity. It is
important to note that strict dosing restrictions must be followed to
prevent rebound headaches from occurring.
DHE is mostly used in the emergency setting for treatment of
moderate to severe migraines; however, patients can be instructed
on how to use this medication at home.2,4 It may be administered
via the intranasal or parenteral route (subcutaneous, intramuscular,
or intravenous). One advantage of DHE is that it is not believed
to cause rebound headache. It is thought to be relatively equally
effective and safe as other acute migraine treatment options.
The most common side effect that may be seen with use of
these medications is nausea and vomiting due to stimulation of
the chemoreceptor trigger zone.2
Pretreatment with an antiemetic
should be considered in patients taking these medications. One
very rare, but serious side effect of these medications is peripheral
ischemia, also known as ergotism. Some signs and symptoms of
ergotism include cold and numb extremities, consistent paresthesias,
and diminished pulses in the extremities. These symptoms are a
direct result of the vasoconstrictive properties of these agents. These
medications should not be used in patients who have renal or hepatic
failure, vascular disease, uncontrolled hypertension, or sepsis.
Corticosteroids. Parenteral hydrocortisone and dexamethasone may
be used as a rescue medication to treat status migrainous, which is a
migraine headache that persists for up to one week.2,4 Corticosteroids
are thought to work by decreasing the peptide-mediated
inflammation in the brain; however the evidence supporting the
efficacy of steroids in acute migraine treatment is inconsistent.6,7