Dihydroergotamine

Dihydroergotamine
Clinical data
Trade names D.H.E. 45, Migranal
AHFS/Drugs.com Monograph
MedlinePlus a603022
License data
Pregnancy
category
  • US: X (Contraindicated)
Routes of
administration		 nasal spray, SC, IM, IV
ATC code N02CA01 (WHO)
Legal status
Legal status
Pharmacokinetic data
Bioavailability 32% Nasal Spary
Biological half-life 9 hours
Excretion Bile
Identifiers
Synonyms (5'α)-9,10-dihydro-12'-hydroxy-2'-methyl-5'-(phenylmethyl)-ergotaman-3',6',18-trione
CAS Number 511-12-6 YesY
PubChem (CID) 10531
IUPHAR/BPS 121
DrugBank DB00320 YesY
ChemSpider 10091 YesY
UNII 436O5HM03C YesY
KEGG D07837 YesY
ChEBI CHEBI:4562 YesY
ChEMBL CHEMBL1732 YesY
ECHA InfoCard 100.025.669
Chemical and physical data
Formula C33H37N5O5
Molar mass 583.678 g/mol
3D model (Jmol) Interactive image
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Dihydroergotamine (/daɪˌhaɪdroʊ.ɜːrˈɡɒtəmiːn/ dy-HY-droh-ur-GOT-ə-meen; brand names D.H.E. 45 and Migranal) is an ergot alkaloid used to treat migraines. It is a derivative of ergotamine. It is administered as a nasal spray or injection and has an efficacy similar to that of sumatriptan. Nausea is a common side effect.[1]

It has similar actions to the triptans, acting as an agonist to the serotonin 5-HT(1D) receptors and causing vasoconstriction of the intracranial blood vessels, but also interacts centrally with dopamine and adrenergic receptors. It can be used to treat acute intractable headache or withdrawal from analgesics.

Description

Dihydroergotamine (DHE) is a semi-synthetic form of ergotamine approved in the US in 1946. Oral bioavailability is poor and it is not available in oral form in the US. DHE is available as Migranal nasal spray and in ampules for subcutaneous, intramuscular and intravenous injection. Efficacy is variable in the nasal spray form with bioavailability 32% of injectable administration. Subcutaneous and intramuscular injections are generally more effective than the nasal spray and can be self-administered by patients.[1] Intravenous injection is considered very effective for severe migraine or status migrainosus. DHE is also used in the treatment of medication overuse headache.[2]
Nausea is a common side effect of IV administration and less common in other modes. Antiemetics can be given prior to DHE to counteract the nausea. Risks and contraindications are similar to the triptans. DHE and triptans should not be taken within 24 hours of each other due to the potential for coronary artery vasospasm. DHE produces no dependence.[3]
MAP Pharmaceuticals submitted an inhaled version of DHE (Levadex) for FDA approval in May 2011. Allergan acquired the rights to the product, now known as Semprana, for nearly $1 billion but the FDA has rejected it 3 times due to quality control issues and it has yet to gain approval.

Recently, DHE has been reported to exhibit efficacy in minimising symptoms of orthostatic intolerance in conditions such as the Postural Orthostatic Tachycardia Syndrome. DHE via its selective venous constrictor action may improve stroke volume through enhanced venous return in these patients.

In 2013 the European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP) has recommended that medicines containing ergot derivatives no longer be used to treat several conditions involving problems with memory, sensation or blood circulation, or to prevent migraine headaches because the risks (increased risk of fibrosis and ergotism) were said to be greater than the benefits in these indications.[4]

References

  1. 1 2 Colman, I.; Brown, M. D.; Innes, G. D.; Grafstein, E.; Roberts, T. E.; Rowe, B. H. (2005). "Parenteral Dihydroergotamine for Acute Migraine Headache: A Systematic Review of the Literature". Annals of Emergency Medicine. 45 (4): 393–401. doi:10.1016/j.annemergmed.2004.07.430. PMID 15795718.
  2. ↑ Saper, J. R.; Silberstein, S.; Dodick, D.; Rapoport, A. (2006). "DHE in the pharmacotherapy of migraine: potential for a larger role". Headache. 46 (Suppl 4): S212–S220. doi:10.1111/j.1526-4610.2006.00605.x. PMID 17078853.
  3. ↑ Schaerlinger, B.; Hickel, P.; Etienne, N.; Guesnier, L.; Maroteaux, L. (2003). "Agonist actions of dihydroergotamine at 5-HT2B and 5-HT2C receptors and their possible relevance to antimigraine efficacy". British Journal of Pharmacology. 140 (2): 277–284. doi:10.1038/sj.bjp.0705437. PMC 1574033Freely accessible. PMID 12970106.
  4. ↑ Restrictions on use of medicines containing ergot derivatives (EMA 2013), Retrieved 3 August 2014
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