dihydroergotamine (Rx)

Brand and Other Names:D.H.E. 45
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

injectable solution

  • 1mg/mL

Migraine & Cluster Headaches

Indicated for acute treatment of migraine headaches with or without aura, and acute treatment of cluster headache episodes

1 mg IV/IM/SQ q1hr PRN; not to exceed 2 mg IV or 3 mg IM/SC per 24-hr period

Not to exceed 6 mg qWeek

Do not use for chronic daily administration

Safety and efficacy not established

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Interactions

Interaction Checker

and dihydroergotamine

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            Contraindicated (48)

            • almotriptan

              dihydroergotamine, almotriptan. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • atazanavir

              atazanavir will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • clarithromycin

              clarithromycin increases toxicity of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Coadministration may result in vasospasm and ischemia of the extremities and other tissues including the CNS.

            • cobicistat

              cobicistat will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Potential for serious and/or life-threatening reactions (eg, acute ergot toxicity characterized by peripheral vasospasm, ischemia of the extremities and other tissues)

            • conivaptan

              conivaptan will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • eletriptan

              dihydroergotamine, eletriptan. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • elvitegravir/cobicistat/emtricitabine/tenofovir DF

              elvitegravir/cobicistat/emtricitabine/tenofovir DF increases levels of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Cobicistat is a CYP3A4 inhibitor; contraindicated with CYP3A4 substrates for which elevated plasma concentrations are associated with serious and/or life-threatening events.

            • erythromycin base

              erythromycin base will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • erythromycin ethylsuccinate

              erythromycin ethylsuccinate will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • erythromycin lactobionate

              erythromycin lactobionate will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • erythromycin stearate

              erythromycin stearate will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • fluvoxamine

              fluvoxamine will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • fosamprenavir

              fosamprenavir will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • frovatriptan

              dihydroergotamine, frovatriptan. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • glyceryl trinitrate pr

              dihydroergotamine decreases effects of glyceryl trinitrate pr by pharmacodynamic antagonism. Contraindicated.

            • idelalisib

              idelalisib will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • imatinib

              imatinib increases levels of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • indinavir

              indinavir will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • isoniazid

              isoniazid will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • itraconazole

              itraconazole will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Increased risk of ergotism leading to cerebral ischemia and/or ischemia of the extremities

            • ketoconazole

              ketoconazole will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • letermovir

              letermovir increases levels of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Coadministration of letermovir and ergot alkaloids is contraindicated due to risk of ergotism.

            • levoketoconazole

              levoketoconazole will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • lopinavir

              lopinavir increases levels of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • mifepristone

              mifepristone increases levels of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Contraindicated with CYP3A substrates that have a narrow therapeutic index .

            • naratriptan

              dihydroergotamine, naratriptan. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • nefazodone

              nefazodone will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • nelfinavir

              nelfinavir will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • nicardipine

              nicardipine increases levels of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • nirmatrelvir

              nirmatrelvir will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Nirmatrelvir/ritonavir is contraindicated with drugs that are highly dependent on CYP3A for clearance and for which elevated concentrations are associated with serious and/or life-threatening reactions.

            • nirmatrelvir/ritonavir

              nirmatrelvir/ritonavir will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Nirmatrelvir/ritonavir is contraindicated with drugs that are highly dependent on CYP3A for clearance and for which elevated concentrations are associated with serious and/or life-threatening reactions.

            • nitroglycerin IV

              dihydroergotamine decreases effects of nitroglycerin IV by pharmacodynamic antagonism. Contraindicated.

            • nitroglycerin sublingual

              dihydroergotamine decreases effects of nitroglycerin sublingual by pharmacodynamic antagonism. Contraindicated.

            • nitroglycerin topical

              dihydroergotamine decreases effects of nitroglycerin topical by pharmacodynamic antagonism. Contraindicated.

            • nitroglycerin transdermal

              dihydroergotamine decreases effects of nitroglycerin transdermal by pharmacodynamic antagonism. Contraindicated.

            • nitroglycerin translingual

              dihydroergotamine decreases effects of nitroglycerin translingual by pharmacodynamic antagonism. Contraindicated.

            • ombitasvir/paritaprevir/ritonavir & dasabuvir (DSC)

              ombitasvir/paritaprevir/ritonavir & dasabuvir (DSC) will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Acute ergot toxicity characterized by vasospasm and tissue ischemia has been associated with coadministration of ritonavir

            • posaconazole

              posaconazole will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • pseudoephedrine

              dihydroergotamine increases effects of pseudoephedrine by pharmacodynamic synergism. Contraindicated. Ergot derivatives may enhance the vasoconstricting effect of pseudoephedrine and eventually significantly increasing blood pressure.

            • quinidine

              quinidine increases levels of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • ritonavir

              ritonavir will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • rizatriptan

              dihydroergotamine, rizatriptan. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • saquinavir

              saquinavir increases levels of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • sumatriptan

              dihydroergotamine, sumatriptan. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • sumatriptan intranasal

              dihydroergotamine, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • tipranavir

              tipranavir increases levels of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • voriconazole

              voriconazole will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • zolmitriptan

              dihydroergotamine, zolmitriptan. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            Serious - Use Alternative (101)

            • abametapir

              abametapir will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. For 2 weeks after abametapir application, avoid taking drugs that are CYP3A4 substrates. If not feasible, avoid use of abametapir.

            • apalutamide

              apalutamide will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Coadministration of apalutamide, a strong CYP3A4 inducer, with drugs that are CYP3A4 substrates can result in lower exposure to these medications. Avoid or substitute another drug for these medications when possible. Evaluate for loss of therapeutic effect if medication must be coadministered. Adjust dose according to prescribing information if needed.

            • aprepitant

              aprepitant will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • armodafinil

              armodafinil will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • artemether/lumefantrine

              artemether/lumefantrine will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • benzphetamine

              dihydroergotamine, benzphetamine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • bosentan

              bosentan will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • bremelanotide

              bremelanotide will decrease the level or effect of dihydroergotamine by Other (see comment). Avoid or Use Alternate Drug. Bremelanotide may slow gastric emptying and potentially reduces the rate and extent of absorption of concomitantly administered oral medications. Avoid use when taking any oral drug that is dependent on threshold concentrations for efficacy. Interactions listed are representative examples and do not include all possible clinical examples.

            • brigatinib

              brigatinib will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Brigatinib induces CYP3A4 in vitro. Coadministration with CYP3A4 substrates, particularly those with a narrow therapeutic index, can result in decreased concentrations and loss of efficacy. If unable to avoid coadministration, monitor CYP3A4 substrate levels and adjust dose as needed.

            • bromocriptine

              dihydroergotamine, bromocriptine. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. The concomitant use of bromocriptine with ergot alkaloids may potentially lead to ergot toxicity; therefore the combination should be avoided.

            • budesonide

              budesonide will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • butabarbital

              butabarbital will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • butalbital

              butalbital will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • carbamazepine

              carbamazepine will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • ceritinib

              ceritinib increases levels of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid concurrent use of CYP3A substrates known to have narrow therapeutic indices or substrates primarily metabolized by CYP3A during treatment with ceritinib; if use of these medications is unavoidable, consider dose reduction.

            • cimetidine

              cimetidine will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • cortisone

              cortisone will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • cyclosporine

              cyclosporine will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • darifenacin

              darifenacin will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • dasatinib

              dasatinib will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • desvenlafaxine

              dihydroergotamine and desvenlafaxine both increase serotonin levels. Avoid or Use Alternate Drug.

            • dexamethasone

              dexamethasone will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • dexfenfluramine

              dexfenfluramine, dihydroergotamine. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Risk of serotonin syndrome.

              dihydroergotamine, dexfenfluramine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • dexmethylphenidate

              dihydroergotamine, dexmethylphenidate. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • dextroamphetamine

              dihydroergotamine, dextroamphetamine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • DHEA, herbal

              DHEA, herbal will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • diethylpropion

              dihydroergotamine, diethylpropion. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • diltiazem

              diltiazem will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • dobutamine

              dihydroergotamine, dobutamine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • dopamine

              dihydroergotamine, dopamine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • dronedarone

              dronedarone will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • efavirenz

              efavirenz will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • enzalutamide

              enzalutamide will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • ephedrine

              dihydroergotamine, ephedrine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • epinephrine

              dihydroergotamine, epinephrine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • eslicarbazepine acetate

              eslicarbazepine acetate will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • etravirine

              etravirine will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • fenfluramine

              fenfluramine, dihydroergotamine. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Risk of serotonin syndrome.

              dihydroergotamine, fenfluramine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • fexinidazole

              fexinidazole will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Fexinidazole inhibits CYP3A4. Coadministration may increase risk for adverse effects of CYP3A4 substrates.

            • fluconazole

              fluconazole will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • fludrocortisone

              fludrocortisone will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • fosphenytoin

              fosphenytoin will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • grapefruit

              grapefruit will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • griseofulvin

              griseofulvin will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • hydrocortisone

              hydrocortisone will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • isocarboxazid

              isocarboxazid and dihydroergotamine both increase serotonin levels. Avoid or Use Alternate Drug.

            • isoproterenol

              dihydroergotamine, isoproterenol. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • ivosidenib

              ivosidenib will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of sensitive CYP3A4 substrates with ivosidenib or replace with alternate therapies. If coadministration is unavoidable, monitor patients for loss of therapeutic effect of these drugs.

            • lapatinib

              lapatinib will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • linezolid

              linezolid and dihydroergotamine both increase serotonin levels. Avoid or Use Alternate Drug. Linezolid may increase serotonin as a result of MAO-A inhibition. If linezolid must be administered, discontinue serotonergic drug immediately and monitor for CNS toxicity. Serotonergic therapy may be resumed 24 hours after last linezolid dose or after 2 weeks of monitoring, whichever comes first.

            • lisdexamfetamine

              dihydroergotamine, lisdexamfetamine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • lonafarnib

              dihydroergotamine will increase the level or effect of lonafarnib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If coadministration of lonafarnib (a sensitive CYP3A substrate) with weak CYP3A inhibitors is unavoidable, reduce to, or continue lonafarnib at starting dose. Closely monitor for arrhythmias and events (eg, syncope, heart palpitations) since lonafarnib effect on QT interval is unknown.

            • lumacaftor/ivacaftor

              lumacaftor/ivacaftor will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Lumacaftor is a strong inducer of CYP3A. Avoid coadministration with sensitive CYP3A substrates or CYP3A substrates with a narrow therapeutic index.

            • lumefantrine

              lumefantrine will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • marijuana

              marijuana will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • methamphetamine

              dihydroergotamine, methamphetamine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • methylene blue

              methylene blue and dihydroergotamine both increase serotonin levels. Avoid or Use Alternate Drug. Methylene blue may increase serotonin as a result of MAO-A inhibition. If methylene blue must be administered, discontinue serotonergic drug immediately and monitor for CNS toxicity. Serotonergic therapy may be resumed 24 hours after last methylene blue dose or after 2 weeks of monitoring, whichever comes first.

            • methylenedioxymethamphetamine

              dihydroergotamine, methylenedioxymethamphetamine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • methylphenidate

              dihydroergotamine, methylphenidate. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • methylprednisolone

              methylprednisolone will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • metronidazole

              metronidazole will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • miconazole vaginal

              miconazole vaginal will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • midodrine

              dihydroergotamine, midodrine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • mobocertinib

              mobocertinib will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If use is unavoidable, increase CYP3A4 substrate dosage in accordance with its prescribing information.

            • nevirapine

              nevirapine will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • nifedipine

              nifedipine will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • nilotinib

              nilotinib will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • norepinephrine

              dihydroergotamine, norepinephrine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • oxcarbazepine

              oxcarbazepine will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • pacritinib

              pacritinib will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • pentobarbital

              pentobarbital will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • pexidartinib

              pexidartinib will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Coadministration of pexidartinib (a CYP3A4 inducer) with sensitive CYP3A substrates may lead to serious therapeutic failures. If concomitant use is unavoidable, increase the CYP3A substrate dosage in accordance with approved product labeling.

            • phendimetrazine

              dihydroergotamine, phendimetrazine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • phenelzine

              phenelzine and dihydroergotamine both increase serotonin levels. Avoid or Use Alternate Drug.

            • phenobarbital

              phenobarbital will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • phentermine

              dihydroergotamine, phentermine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • phenylephrine

              dihydroergotamine, phenylephrine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • phenylephrine PO

              dihydroergotamine, phenylephrine PO. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • phenytoin

              phenytoin will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • prednisone

              prednisone will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • primidone

              primidone will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • procarbazine

              procarbazine and dihydroergotamine both increase serotonin levels. Avoid or Use Alternate Drug.

            • propylhexedrine

              dihydroergotamine, propylhexedrine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • quinupristin/dalfopristin

              quinupristin/dalfopristin will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • rifabutin

              rifabutin will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • rifampin

              rifampin will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • rifapentine

              rifapentine will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • rufinamide

              rufinamide will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • secobarbital

              secobarbital will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • serdexmethylphenidate/dexmethylphenidate

              dihydroergotamine, serdexmethylphenidate/dexmethylphenidate. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • sotorasib

              sotorasib will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If use is unavoidable, refer to the prescribing information of the CYP3A4 substrate for dosage modifications

            • St John's Wort

              St John's Wort will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • topiramate

              topiramate will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • tranylcypromine

              tranylcypromine and dihydroergotamine both increase serotonin levels. Avoid or Use Alternate Drug.

            • triamcinolone acetonide injectable suspension

              triamcinolone acetonide injectable suspension will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • tucatinib

              tucatinib will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid concomitant use of tucatinib with CYP3A substrates, where minimal concentration changes may lead to serious or life-threatening toxicities. If unavoidable, reduce CYP3A substrate dose according to product labeling.

            • verapamil

              verapamil will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • voxelotor

              voxelotor will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Voxelotor increases systemic exposure of sensitive CYP3A4 substrates. Avoid coadministration with sensitive CYP3A4 substrates with a narrow therapeutic index. Consider dose reduction of the sensitive CYP3A4 substrate(s) if unable to avoid.

            • xylometazoline

              dihydroergotamine, xylometazoline. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • yohimbine

              dihydroergotamine, yohimbine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • zafirlukast

              zafirlukast will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            Monitor Closely (112)

            • 5-HTP

              5-HTP and dihydroergotamine both increase serotonin levels. Use Caution/Monitor.

            • almotriptan

              almotriptan and dihydroergotamine both increase serotonin levels. Use Caution/Monitor.

            • amitriptyline

              amitriptyline and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • amoxapine

              amoxapine and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • aripiprazole

              dihydroergotamine, aripiprazole. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • asenapine

              dihydroergotamine, asenapine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • atogepant

              dihydroergotamine will increase the level or effect of atogepant by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • avapritinib

              dihydroergotamine will increase the level or effect of avapritinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • axitinib

              dihydroergotamine increases levels of axitinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • belzutifan

              belzutifan will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. If unable to avoid coadministration of belzutifan with sensitive CYP3A4 substrates, consider increasing the sensitive CYP3A4 substrate dose in accordance with its prescribing information.

            • berotralstat

              berotralstat will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Monitor or titrate substrate dose when berotralstat is coadministered with narrow therapeutic index drugs that are CYP3A substrates.

            • buspirone

              buspirone and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • cariprazine

              dihydroergotamine, cariprazine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • citalopram

              citalopram and dihydroergotamine both increase serotonin levels. Use Caution/Monitor. Combination may increase risk of serotonin syndrome or neuroleptic malignant syndrome-like reactions.

            • clomipramine

              clomipramine and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • clozapine

              dihydroergotamine, clozapine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • cocaine

              cocaine and dihydroergotamine both increase serotonin levels. Use Caution/Monitor.

            • crizotinib

              crizotinib increases levels of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Coadministration of crizotinib with CYP3A substrates with narrow therapeutic indices should be avoided.

            • dabrafenib

              dabrafenib will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely.

            • deferasirox

              deferasirox will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Use ergot alkaloids with caution with less potent CYP3A4 inhibitors.

            • desipramine

              desipramine and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • dexfenfluramine

              dexfenfluramine and dihydroergotamine both increase serotonin levels. Use Caution/Monitor.

            • dextroamphetamine

              dextroamphetamine and dihydroergotamine both increase serotonin levels. Use Caution/Monitor.

            • dextromethorphan

              dextromethorphan and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • doxepin

              doxepin and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • duloxetine

              duloxetine and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • duvelisib

              duvelisib will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. will increase the level or effect of

            • elagolix

              elagolix will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Elagolix is a weak-to-moderate CYP3A4 inducer. Monitor CYP3A substrates if coadministered.

            • eletriptan

              eletriptan and dihydroergotamine both increase serotonin levels. Use Caution/Monitor.

            • eluxadoline

              eluxadoline increases levels of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Caution when CYP3A substrates that have a narrow therapeutic index are coadministered with eluxadoline.

            • encorafenib

              encorafenib, dihydroergotamine. affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Encorafenib both inhibits and induces CYP3A4 at clinically relevant plasma concentrations. Coadministration of encorafenib with sensitive CYP3A4 substrates may result in increased toxicity or decreased efficacy of these agents.

            • ergotamine

              dihydroergotamine and ergotamine both increase serotonin levels. Use Caution/Monitor.

            • escitalopram

              escitalopram and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • fedratinib

              fedratinib will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Adjust dose of drugs that are CYP3A4 substrates as necessary.

            • fenfluramine

              dihydroergotamine and fenfluramine both increase serotonin levels. Use Caution/Monitor.

              dihydroergotamine decreases effects of fenfluramine by pharmacodynamic antagonism. Use Caution/Monitor. Potent serotonin receptor antagonists may decrease fenfluramine efficacy. If coadministered, monitor appropriately.

            • ferric maltol

              ferric maltol, dihydroergotamine. Either increases levels of the other by unspecified interaction mechanism. Modify Therapy/Monitor Closely. Coadministration of ferric maltol with certain oral medications may decrease the bioavailability of either ferric maltol and some oral drugs. For oral drugs where reductions in bioavailability may cause clinically significant effects on its safety or efficacy, separate administration of ferric maltol from these drugs. Duration of separation may depend on the absorption of the medication concomitantly administered (eg, time to peak concentration, whether the drug is an immediate or extended release product).

            • finerenone

              dihydroergotamine will increase the level or effect of finerenone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Monitor serum potassium during initiation and dosage adjustment of either finererone or weak CYP3A4 inhibitors. Adjust finererone dosage as needed.

            • flibanserin

              dihydroergotamine will increase the level or effect of flibanserin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Increased flibanserin adverse effects may occur if coadministered with multiple weak CYP3A4 inhibitors.

            • fluoxetine

              fluoxetine and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • fluphenazine

              dihydroergotamine, fluphenazine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • fluvoxamine

              fluvoxamine and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • frovatriptan

              frovatriptan and dihydroergotamine both increase serotonin levels. Use Caution/Monitor.

            • glycerol phenylbutyrate

              glycerol phenylbutyrate will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Glycerol phenylbutyrate is a weak inducer of CYP3A4. Monitor for decreased efficacy of CYP3A4 substrates that have a narrow therapeutic index.

            • haloperidol

              dihydroergotamine, haloperidol. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • iloperidone

              iloperidone increases levels of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Iloperidone is a time-dependent CYP3A inhibitor and may lead to increased plasma levels of drugs predominantly eliminated by CYP3A4.

              dihydroergotamine, iloperidone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • imipramine

              imipramine and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • isavuconazonium sulfate

              dihydroergotamine will increase the level or effect of isavuconazonium sulfate by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              isavuconazonium sulfate will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • isoniazid

              dihydroergotamine and isoniazid both increase serotonin levels. Use Caution/Monitor.

            • istradefylline

              istradefylline will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Istradefylline 40 mg/day increased peak levels and AUC of CYP3A4 substrates in clinical trials. This effect was not observed with istradefylline 20 mg/day. Consider dose reduction of sensitive CYP3A4 substrates.

            • L-tryptophan

              dihydroergotamine and L-tryptophan both increase serotonin levels. Use Caution/Monitor.

            • lemborexant

              dihydroergotamine will increase the level or effect of lemborexant by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Lower nightly dose of lemborexant recommended if coadministered with weak CYP3A4 inhibitors. See drug monograph for specific dosage modification.

            • levomilnacipran

              levomilnacipran and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • lithium

              dihydroergotamine and lithium both increase serotonin levels. Use Caution/Monitor.

            • lofepramine

              lofepramine and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • lomitapide

              dihydroergotamine increases levels of lomitapide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Lomitapide dose should not exceed 30 mg/day.

            • loxapine

              dihydroergotamine, loxapine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • loxapine inhaled

              dihydroergotamine, loxapine inhaled. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • lsd

              dihydroergotamine and lsd both increase serotonin levels. Use Caution/Monitor.

            • lurasidone

              dihydroergotamine, lurasidone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • maprotiline

              maprotiline and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • meperidine

              dihydroergotamine and meperidine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • midazolam intranasal

              dihydroergotamine will increase the level or effect of midazolam intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Coadministration of mild CYP3A4 inhibitors with midazolam intranasal may cause higher midazolam systemic exposure, which may prolong sedation.

            • milnacipran

              milnacipran and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • minocycline

              minocycline, dihydroergotamine. Either increases toxicity of the other by Mechanism: unknown. Use Caution/Monitor. coadministration of ergot alkaloids and tetracyclines increases risk of ergotism.

            • mirtazapine

              dihydroergotamine and mirtazapine both increase serotonin levels. Use Caution/Monitor.

            • mitotane

              mitotane decreases levels of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Mitotane is a strong inducer of cytochrome P-4503A4; monitor when coadministered with CYP3A4 substrates for possible dosage adjustments.

            • molindone

              dihydroergotamine, molindone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • morphine

              dihydroergotamine and morphine both increase serotonin levels. Use Caution/Monitor.

            • naratriptan

              naratriptan and dihydroergotamine both increase serotonin levels. Use Caution/Monitor.

            • nefazodone

              nefazodone and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • nitroglycerin rectal

              nitroglycerin rectal will increase the level or effect of dihydroergotamine by Other (see comment). Use Caution/Monitor. Oral administration of nitroglycerin markedly decreases the first-pass metabolism of dihydroergotamine and consequently increases its oral bioavailability. Ergotamine is known to precipitate angina pectoris. Therefore the possibility of ergotism in patients receiving nitroglycerin should be considered.

            • nortriptyline

              nortriptyline and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • olanzapine

              dihydroergotamine, olanzapine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • palbociclib

              palbociclib will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. The dose of sensitive CYP3A substrates with a narrow therapeutic index may need to be reduced if coadministered with palbociclib

            • paliperidone

              dihydroergotamine, paliperidone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • paroxetine

              paroxetine and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • pentazocine

              dihydroergotamine and pentazocine both increase serotonin levels. Use Caution/Monitor.

            • perphenazine

              dihydroergotamine, perphenazine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • pimavanserin

              dihydroergotamine, pimavanserin. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • pimozide

              dihydroergotamine, pimozide. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • pitolisant

              pitolisant will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Pitolisant is a borderline/weak inducer of CYP3A4. Monitor sensitive CYP3A4 substrates for reduced effectiveness if coadministered.

            • protriptyline

              protriptyline and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • quetiapine

              dihydroergotamine, quetiapine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • rasagiline

              rasagiline and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • ribociclib

              ribociclib will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Caution if ribociclib is coadministered with sensitive CYP3A4 substrates that have a narrow therapeutic index. Dose reduction for sensitive CYP3A4 substrates may be needed.

            • risperidone

              dihydroergotamine, risperidone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • rizatriptan

              rizatriptan and dihydroergotamine both increase serotonin levels. Use Caution/Monitor.

            • ropeginterferon alfa 2b

              ropeginterferon alfa 2b will increase the level or effect of dihydroergotamine by Other (see comment). Use Caution/Monitor. Certain proinflammatory cytokines, including interferons, can suppress CYP450 enzymes resulting in increased exposures of some CYP substrates. Therefore, monitor patients who are receiving concomitant drugs that are CYP450 substrates with a narrow therapeutic index from toxicities to such drugs.

            • rucaparib

              rucaparib will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Adjust dosage of CYP3A4 substrates, if clinically indicated.

            • SAMe

              dihydroergotamine and SAMe both increase serotonin levels. Use Caution/Monitor.

            • schisandra

              schisandra will increase the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • selegiline

              selegiline and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • selegiline transdermal

              selegiline transdermal and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • sertraline

              sertraline and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • sofosbuvir/velpatasvir

              sofosbuvir/velpatasvir increases levels of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Velpatasvir inhibits CYP3A4. Caution if coadministered with drugs with narrow therapeutics indexes.

            • St John's Wort

              dihydroergotamine and St John's Wort both increase serotonin levels. Modify Therapy/Monitor Closely.

            • stiripentol

              stiripentol, dihydroergotamine. affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Stiripentol is a CYP3A4 inhibitor and inducer. Monitor CYP3A4 substrates coadministered with stiripentol for increased or decreased effects. CYP3A4 substrates may require dosage adjustment.

            • sumatriptan

              sumatriptan and dihydroergotamine both increase serotonin levels. Use Caution/Monitor.

            • sumatriptan intranasal

              sumatriptan intranasal and dihydroergotamine both increase serotonin levels. Use Caution/Monitor.

            • tazemetostat

              tazemetostat will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              dihydroergotamine will increase the level or effect of tazemetostat by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • tecovirimat

              tecovirimat will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Tecovirimat is a weak CYP3A4 inducer. Monitor sensitive CYP3A4 substrates for effectiveness if coadministered.

            • telotristat ethyl

              telotristat ethyl will decrease the level or effect of dihydroergotamine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Telotristat ethyl induces CYP3A4 and may reduce systemic exposure of sensitive CYP3A4 substrates. Monitor for suboptimal efficacy and consider increasing the dose of the CYP3A4 substrate.

            • thiothixene

              dihydroergotamine, thiothixene. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • tinidazole

              dihydroergotamine will increase the level or effect of tinidazole by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • tramadol

              dihydroergotamine and tramadol both increase serotonin levels. Use Caution/Monitor.

            • trazodone

              trazodone and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • trifluoperazine

              dihydroergotamine, trifluoperazine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • trimipramine

              trimipramine and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • ustekinumab

              ustekinumab, dihydroergotamine. Other (see comment). Use Caution/Monitor. Comment: Formation of CYP450 enzymes can be altered by increased levels of certain cytokines during chronic inflammation; thus, normalizing the formation of CYP450 enzymes. Upon initiation or discontinuation of ustekinumab in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, consider monitoring for therapeutic effect.

            • venlafaxine

              venlafaxine and dihydroergotamine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • ziprasidone

              dihydroergotamine, ziprasidone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • zolmitriptan

              zolmitriptan and dihydroergotamine both increase serotonin levels. Use Caution/Monitor.

            Minor (21)

            • acebutolol

              dihydroergotamine, acebutolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • atenolol

              dihydroergotamine, atenolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • betaxolol

              dihydroergotamine, betaxolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • bisoprolol

              dihydroergotamine, bisoprolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • carvedilol

              dihydroergotamine, carvedilol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • celiprolol

              dihydroergotamine, celiprolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • esmolol

              dihydroergotamine, esmolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • green tea

              green tea increases levels of dihydroergotamine by enhancing GI absorption. Applies only to oral form of both agents. Minor/Significance Unknown. Due to caffeine content.

            • labetalol

              dihydroergotamine, labetalol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • metoprolol

              dihydroergotamine, metoprolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • nadolol

              dihydroergotamine, nadolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • nebivolol

              dihydroergotamine, nebivolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • nicotine inhaled

              dihydroergotamine, nicotine inhaled. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • nicotine intranasal

              dihydroergotamine, nicotine intranasal. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • penbutolol

              dihydroergotamine, penbutolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • pindolol

              dihydroergotamine, pindolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • propranolol

              dihydroergotamine, propranolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • ruxolitinib

              dihydroergotamine will increase the level or effect of ruxolitinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • ruxolitinib topical

              dihydroergotamine will increase the level or effect of ruxolitinib topical by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • sotalol

              dihydroergotamine, sotalol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • timolol

              dihydroergotamine, timolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

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            Adverse Effects

            Frequency Not Defined

            Common

            • Dizziness
            • Paresthesia
            • Nausea
            • Vomiting
            • Taste sense altered, Nasal spray
            • Nasal irritation
            • Throat irritation

            Serious

            • Peripheral ischemia (rare)
            • Vasospasm
            • Tachycardia
            • Cerebrovascular disease
            • Ergotism (rare)
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            Warnings

            Black Box Warnings

            Serious and/or life-threatening peripheral ischemia has been reported with coadministration of this drug with potent CYP 3A4 inhibitors (including protease inhibitors and macrolide antibiotics)

            Because CYP3A4 inhibition elevates the serum ergotamine levels, the risk of vasospasm leading to cerebral ischemia and/or ischemia of the extremities is increased

            Concurrent use of potent CYP3A4 inhibitors is contraindicated

            Contraindications

            Coadministration with potent CYP 3A4 inhibitors (ritonavir, nelfinavir, indinavir, erythromycin, clarithromycin, troleandomycin, ketoconazole, itraconazole)

            Patients with ischemic heart disease (angina pectoris, history of myocardial infarction, or documented silent ischemia) or patients who have clinical symptoms or findings consistent with coronary artery vasospasm including Prinzmetal’s variant angina

            Uncontrolled hypertension

            Within 24 hours of 5-HT 1 agonists (eg, sumatriptan), ergotamine-containing or ergot-type medications or methysergide

            Patients with hemiplegic or basilar migraine

            Patients with known peripheral arterial disease, sepsis, following vascular surgery, and severely impaired hepatic or renal function

            During pregnancy

            Documented hypersensitivity to drug or excipients

            Nursing mothers

            Coadministration with peripheral and central vasoconstrictors

            Caution

            Only for use where a clear diagnostic of migraine has been established

            Pleural and retroperitoneal fibrosis in patients following prolonged daily use of injectable dihydroergotamine mesylate reported; prolonged daily use of other ergot alkaloid drugs associated with cardiac valvular fibrosis (rare); therapy should not exceed dosing guidelines and should not be used for chronic daily administration

            Potential for adverse cardiac events exists; serious adverse cardiac events, including acute myocardial infarction, life-threatening disturbances of cardiac rhythm, and death reported to have occurred following administration of dihydroergotamine mesylate injection; considering the extent of use of dihydroergotamine mesylate in patients with migraine, the incidence of these events is extremely low

            Significant elevation in blood pressure reported on rare occasions in patients with and without a history of hypertension treated with this drug; therapy is contraindicated in patients with uncontrolled hypertension

            Therapy may cause coronary artery vasospasm; patients who experience signs or symptoms suggestive of angina following its administration should be evaluated for presence of CAD or a predisposition to variant angina before receiving additional doses

            Patients who experience other symptoms or signs suggestive of decreased arterial flow, such as ischemic bowel syndrome or Raynaud’s syndrome following the use of any 5-HT agonist are candidates for further evaluation

            Overuse headache

            • Overuse of acute migraine drugs (eg, ergotamines, triptans, opioids, or a combination of these drugs for 10 or more days per month) may lead to exacerbation of headache (eg, medication overuse headache)
            • Medication overuse headache may present as migraine-like daily headaches or as a marked increase in frequency of migraine attacks; detoxification of patients including withdrawal of overused drugs and treatment of withdrawal symptoms (which often includes a transient worsening of headache) may be necessary

            Vasospasm related events

            • Therapy may cause vasospastic reactions other than coronary artery vasospasm; myocardial, peripheral vascular, and colonic ischemia have been reported with therapy; treatment associated vasospastic phenomena may also cause muscle pains, numbness, coldness, pallor, and cyanosis of the digits
            • In patients with compromised circulation, persistent vasospasm may result in gangrene or death; therapy should be discontinued immediately if signs or symptoms of vasoconstriction develop

            Cardiovascular events

            • Cerebral hemorrhage, subarachnoid hemorrhage, stroke, and other cerebrovascular events reported in patients receiving therapy; some have resulted in fatalities
            • In a number of cases, it appears possible that the cerebrovascular events were primary, the drug having been administered in the incorrect belief that the symptoms experienced were a consequence of migraine, when they were not
            • It should be noted that patients with migraine may be at increased risk of certain cerebrovascular events (eg, stroke, hemorrhage, transient ischemic attack)

            Risk of myocardial ischemia and/or infarction

            • Not for use by patients with documented ischemic or vasospastic coronary artery disease; strongly recommended not to be given to patients in whom unrecognized coronary artery disease (CAD) predicted by the presence of risk factors (eg, hypertension, hypercholesterolemia, smoker, obesity, diabetes, strong family history of CAD, females who are surgically or physiologically postmenopausal, or males who are over 40 years of age) unless a cardiovascular evaluation provides satisfactory clinical evidence that the patient is reasonably free of coronary artery and ischemic myocardial disease or other significant underlying cardiovascular disease
            • The sensitivity of cardiac diagnostic procedures to detect cardiovascular disease or predisposition to coronary artery vasospasm is modest, at best; if, during cardiovascular evaluation, the patient’s medical history or electrocardiographic investigations reveal findings indicative of or consistent with coronary artery vasospasm or myocardial ischemia, do not administer
            • For patients with risk factors predictive of CAD who are determined to have a satisfactory cardiovascular evaluation, strongly recommended that administration of first dose take place in the setting of a physician’s office or similar medically staffed and equipped facility unless patient has previously received dihydroergotamine mesylate
            • Because cardiac ischemia can occur in absence of clinical symptoms, consideration should be given to obtaining on first occasion of use an electrocardiogram (ECG) during interval immediately following therapy administration in those patients with risk factors
            • Recommended that patients who are intermittent long-term users of this drug and who have or acquire risk factors predictive of CAD, undergo periodic interval cardiovascular evaluation as they continue to receive therapy
            • The systematic approach described above is currently recommended as a method to identify patients in whom this drug may be used to treat migraine headaches with an acceptable margin of cardiovascular safety

            Drug interaction overview

            • Serious adverse events reported with the coadministration of dihydroergotamine and potent CYP 3A4 inhibitors, such as protease inhibitors and macrolide antibiotics, resulting in vasospasm that led to cerebral ischemia and/or ischemia of extremities
            • Administer other less potent CYP 3A4 inhibitors with caution; less potent inhibitors include saquinavir, nefazodone, fluconazole, grapefruit juice, fluoxetine, fluvoxamine, zileuton, clotrimazole (list not exhaustive)
            • Not for use with peripheral vasoconstrictor as it may cause synergistic elevation of blood pressure
            • Effects of this drug in coronary artery vasospasm may be additive if coadministered with sumatriptan; should not be taken within 24 hours of each other
            • There are reports that propranolol may potentiate the vasoconstrictive action of ergotamine by blocking the vasodilating property of epinephrine
            • Weakness, hyperreflexia, and incoordination reported rarely when 5-HT 1 agonists coadministered with SSRIs (eg, fluoxetine, fluvoxamine, paroxetine, sertraline); there have been no reported cases from spontaneous reports of drug interaction between SSRI’s and this drug
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            Pregnancy & Lactation

            Pregnancy

            Available data from published literature indicate an increased risk of preterm delivery with use during pregnancy; avoid use during pregnancy; data collected over decades have shown no increased risk of major birth defects or miscarriage with use

            Animal data

            • In animal reproduction studies, adverse effects on development were observed following intranasal administration of dihydroergotamine mesylate during pregnancy (decreased fetal body weight and/or skeletal ossification) in rats and rabbits or during pregnancy and lactation in rats (decreased body weight and impaired reproductive function in the offspring) at doses that were not associated with maternal toxicity
            • Based on mechanism of action and findings from thepublished literature, the drug may cause preterm labor. Avoid use during pregnancy

            Fertility

            • Intranasal administration of dihydroergotamine to rats at doses up to 1.6 mg/day was not associated with adverse effects on fertility

            Lactation

            There are no data on presence of this drug in human milk; however, ergotamine, a related drug, is present in human milk; there are reports of vomiting, diarrhea, weak pulse, and unstable blood pressure in breastfed infants exposed to ergotamine; this drug may reduce milk supply because it may decrease prolactin levels

            Pregnancy Categories

            A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA: Information not available.

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            Pharmacology

            Mechanism of Action

            Binds with high affinity to 5-HT-1Dα and 5-HT-1Dβ; also bind to serotonin 5-HT-1A, -2A, and -2C receptors, noradrenaline α2A, α2B, and alpha receptors, and dopamine D2L and D3 receptors

            Therapeutic activity attributed to agonist effect at 5-HT-1D receptors, which includes vasoconstriction of intracranial blood vessels, or activation of 5-HT1D may inhibit proinflammatory neuropeptide release

            Pharmacokinetics

            Half-Life: 28 hr

            Protein Bound: 93%

            Metabolism: liver, by CYP3A4

            Excretion: mainly in feces; urine: <10%

            Onset

            • IM: 15-30 min
            • IV: <5 minIntranasal: 30 min

            Duration

            • IM: 3-4 hr
            • SC/IV: 8 hr
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            Administration

            IV/IM Administration

            Administer by IM, IV, or SC injection

            IV: 1 mg or fraction thereof over 1 min

            After the initial dose is administered, patient should lie down & relax in a quiet, darkened room

            Should not be used for chronic daily administration

            Storage

            Store below 25°C (77°F)

            Do not refrigerate or freeze

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            Images

            BRAND FORM. UNIT PRICE PILL IMAGE
            Migranal nasal
            -
            0.5 mg/pump act. (4 mg/mL) aerosol
            dihydroergotamine nasal
            -
            0.5 mg/pump act. (4 mg/mL) aerosol
            dihydroergotamine nasal
            -
            0.5 mg/pump act. (4 mg/mL) aerosol
            dihydroergotamine injection
            -
            1 mg/mL solution
            dihydroergotamine injection
            -
            1 mg/mL solution
            dihydroergotamine injection
            -
            1 mg/mL solution
            dihydroergotamine injection
            -
            1 mg/mL solution

            Copyright © 2010 First DataBank, Inc.

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            Patient Handout

            Select a drug:
            Patient Education
            dihydroergotamine injection

            DIHYDROERGOTAMINE - INJECTION

            (dye-HI-dro-er-GOT-uh-meen)

            COMMON BRAND NAME(S): D.H.E.45

            WARNING: This medication has rarely caused a very serious lack of blood flow to the hands and feet (peripheral ischemia) or to the brain, which could cause a stroke. The risk is increased when this medication is taken with other drugs that can affect the removal of dihydroergotamine from your body. Examples include azole antifungals (such as ketoconazole, itraconazole), cobicistat, mifepristone, certain antidepressants (such as nefazodone), macrolide antibiotics (such as clarithromycin, erythromycin, troleandomycin), HIV NNRTIs (such as delavirdine), HIV protease inhibitors (such as ritonavir, nelfinavir, indinavir), SSRIs (such as fluoxetine, paroxetine, fluvoxamine), among others.

            USES: Dihydroergotamine is used to treat migraine headaches and cluster headaches. It is not recommended for migraines that affect only one side of the brain (hemiplegic migraine) or the base of the brain/neck area (basilar migraine), or to prevent migraines from occurring.Dihydroergotamine is an ergot medication that helps narrow widened blood vessels in the head, thereby reducing the throbbing effects of these headaches.

            HOW TO USE: Read the Patient Information Leaflet provided by your pharmacist before you start using dihydroergotamine and each time you get a refill. If you have any questions, consult your doctor or pharmacist.Inject this medication into a vein, into a muscle, or under the skin as directed by your doctor. Dosage is based on your medical condition and response to treatment. Usually, this medication should be used only as needed. It is not meant for long-term daily use. This medication works best if it is taken as the first signs of the headache occur. If you wait until the headache has worsened, the medication may not work as well.If your headache returns or you have no relief from the first dose, you may repeat the dose 1 hour after the first dose, but only if instructed to do so by your doctor.If this medication is given into a muscle or under the skin, a third dose may be given 1 hour after the second dose if needed. Do not use more than 3 milliliters in 24 hours or 6 milliliters in a week.If this medication is given into a vein, do not use more than 2 milliliters in 24 hours or 6 milliliters in a week.If you are giving this medication to yourself at home, learn all preparation and usage instructions from your health care professional. The solution is normally clear and colorless. Before using, check this product visually for particles or discoloration. If either is present, do not use the liquid. Learn how to store and discard medical supplies safely.Other "ergot" drugs (such as ergotamine, methysergide), or "triptan-type" drugs (such as sumatriptan) should not be used within 24 hours of this drug.If you are using drugs for migraine attacks on 10 or more days each month, the drugs may actually make your headaches worse (medication overuse headache). Do not use medications more often or for longer than directed. Tell your doctor if you need to use this medication more often, or if the medication is not working as well, or if your headaches get worse.

            SIDE EFFECTS: Dizziness, drowsiness, headache, nausea, vomiting, diarrhea, flushing, or increased sweating may occur. If any of these effects last or get worse, tell your doctor.Remember that this medication has been prescribed because your doctor has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.Tell your doctor right away if you have any serious side effects, including: slow/fast/irregular heartbeat, tingling/pain/coldness in the fingers/toes, whitish fingers/toes/nails, loss of feeling in the fingers/toes, bluish hands/feet, muscle pain/weakness in the arms/legs, severe stomach/abdominal pain, lower back pain, signs of kidney problems (such as change in the amount of urine).Get medical help right away if you have any very serious side effects, including: difficult/painful breathing, chest pain, confusion, trouble speaking, weakness on one side of the body, vision problems.A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

            PRECAUTIONS: Before using this medication, tell your doctor or pharmacist if you are allergic to it; or to other ergot alkaloids (such as ergotamine); or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.Before using this medication, tell your doctor or pharmacist your medical history, especially of: blood circulation disease (such as peripheral arterial disease, Raynaud's disease), heart disease (such as coronary artery disease, angina, heart attack), stroke, diabetes, family history of heart disease, high blood pressure, high cholesterol, liver disease, kidney disease, severe blood infection (sepsis), recent blood vessel surgery, stomach/intestinal problems (such as ischemic bowel syndrome), smoking/tobacco use, permanent ending of menstrual periods due to age/surgery/hormonal changes (post-menopausal).This drug may make you dizzy. Alcohol or marijuana (cannabis) can make you more dizzy. Do not drive, use machinery, or do anything that needs alertness until you can do it safely. Limit alcoholic beverages. Talk to your doctor if you are using marijuana (cannabis). Remember that alcohol may be a cause of headaches.Using tobacco/nicotine products while using this medication can increase the risk of serious side effects such as heart problems (such as chest pain, fast/slow/irregular heartbeat) and decreased blood supply to the brain/hands/feet. Do not use tobacco while taking this medication. If you smoke, talk to your doctor about how to stop smoking.Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).Tell your doctor if you are pregnant or plan to become pregnant. You should not become pregnant while using dihydroergotamine. Dihydroergotamine may harm an unborn baby. If you become pregnant, talk to your doctor right away about the risks and benefits of this medication.This drug may pass into breast milk. Because of the possible risk to the infant, breast-feeding is not recommended while using this drug and for 3 days after the last dose. Consult your doctor before breast-feeding.

            DRUG INTERACTIONS: See also Warning and How to Use sections.Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.Some products that may interact with this drug include: bronchodilators/decongestants/stimulants (such as epinephrine, pseudoephedrine, methylphenidate, amphetamine).If you also take "triptan" migraine drugs (such as sumatriptan, rizatriptan), you will need to separate your "triptan" dose from your dose of this medication to reduce the risk of serious side effects. Ask your doctor how long you should wait between your doses of these drugs.Some products have ingredients that could raise your heart rate or blood pressure. Tell your pharmacist what products you are using, and ask how to use them safely (especially cough-and-cold products, diet aids, or other migraine medications).

            OVERDOSE: If someone has overdosed and has serious symptoms such as passing out or trouble breathing, call 911. Otherwise, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center. Symptoms of overdose may include: severe dizziness/drowsiness, loss of feeling in the fingers/toes, rapid/weak heartbeat, bluish hands/feet, seizures.

            NOTES: Do not share this medication with others.Laboratory and/or medical tests (such as heart tests) may be performed to monitor your progress.Certain foods/beverages or food additives (such as red wine, cheese, chocolate, monosodium glutamate, alcohol) as well as some lifestyle patterns (such as irregular eating/sleeping habits, stress) may bring about a migraine headache. Avoiding these "triggers" may help decrease the frequency of migraine headaches. Consult your doctor for more details.

            MISSED DOSE: Not applicable.

            STORAGE: Store at room temperature away from light and moisture. Do not refrigerate or freeze. Do not store in the bathroom. Keep all medications away from children and pets.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.

            Information last revised May 2022. Copyright(c) 2022 First Databank, Inc.

            IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.

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            Formulary

            FormularyPatient Discounts

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            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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            Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.