Section 02 · Monograph

Dihydroergotamine

Reviewed Nov 2026FDA label

Migranal / TrudhesaErgot alkaloid

Indications

Acute treatment of migraine with or without aura in adults (nasal spray: Migranal, Trudhesa)FDA-labeled
Injectable formulation (IM/IV/SC): acute treatment of migraine and cluster headache episodes, including use in status migrainosus (repetitive IV dosing protocols)FDA-labeled

Nonselective agonist/partial agonist at 5-HT1B/1D (and other 5-HT), alpha-adrenergic, and dopaminergic receptors; produces direct cranial and peripheral vasoconstriction and inhibits trigeminal neuropeptide release, interrupting migraine pain transmission

Migranal nasal spray: 0.5 mg (1 spray) in each nostril, repeat once after 15 minutes for a total of 2 mg (4 sprays) per attack; max 3 mg/24 hours and 4 mg/week
Trudhesa nasal spray: 1.45 mg total (one 0.725 mg spray per nostril); may repeat ≥1 hour later; max 2 doses/24 hours and 3 doses/7 days
Injection (status migrainosus, in-hospital use): typically 0.5–1 mg IV every 8 hours, or IM/SC dosing per institutional protocol, generally not exceeding 2 mg IV or 3 mg IM/SC per day and 6 mg per week — administered with an antiemetic
Not intended for chronic daily use — restrict to intermittent/episodic dosing to avoid medication overuse and fibrotic complications

Concomitant use of potent CYP3A4 inhibitors — protease inhibitors, macrolide antibiotics, and azole antifungals — due to risk of severe peripheral/cerebral ischemia (ergotism)
Ischemic heart disease, coronary artery vasospasm, or history of myocardial infarction
Uncontrolled hypertension
Peripheral arterial disease, sepsis, or recent vascular surgery
Hemiplegic or basilar migraine
Use within 24 hours of a triptan or another ergotamine-type agent
Severe hepatic or renal impairment
Pregnancy (oxytocic/uterotonic effects — fetal harm) and breastfeeding
Known hypersensitivity to ergot alkaloids

Potent CYP3A4 inhibitors — contraindicated; can precipitate serious/life-threatening peripheral vasospasm and ischemia (ergotism)
Other 5-HT1 agonists (triptans) or ergot-type drugs within 24 hours — additive vasospastic risk
Beta-blockers may potentiate peripheral vasoconstriction
Nicotine use increases risk of vasoconstriction/ischemia
Other vasoconstrictors/peripheral vasoconstricting agents — avoid concomitant use

Common (nasal spray): rhinitis, altered taste, nausea/vomiting, application-site/nasal irritation, dizziness, somnolence, pharyngitis
Serious: coronary vasospasm, myocardial infarction, arrhythmias, cerebral/subarachnoid hemorrhage or stroke, peripheral ischemia (numbness, coldness, cyanosis, gangrene), Raynaud's phenomenon
Pleural and retroperitoneal fibrosis and cardiac valvular fibrosis with prolonged/frequent use
Medication overuse headache with frequent use (e.g., ≥10 days/month)

Cardiovascular risk evaluation prior to first dose in patients with risk factors; consider baseline ECG and administering first dose in a monitored setting for high-risk patients
Monitor for symptoms of vasospasm/ischemia (chest pain, extremity coldness/numbness/discoloration, abdominal pain)
Periodic reassessment of cardiovascular status with long-term intermittent use
Track frequency of use to avoid medication overuse and rebound headache

Contraindicated in pregnancy — oxytocic/uterotonic effects can cause uterine vasoconstriction and fetal harm
Contraindicated during breastfeeding — ergot alkaloids are excreted in breast milk and have been associated with vomiting, diarrhea, weak pulse, and unstable blood pressure in nursing infants