Ergot Derivatives
Ergot derivatives (dihydroergotamine and ergotamine) are an older class of migraine medications. Because of the high incidence of side effects, especially nausea as an immediate side effect, complex vascular problems when used over the long term, and the availability of more effective therapies, these drugs are typically only used in patients who have severe side effects or allergies to other migraine medication. Ergot derivatives only relieve the pain symptoms of migraine, while other symptoms associated with a migraine attack may linger. Ergotamine can actually prolong aura in patients who experience migraine with aura, and the drugs can also increase nausea and vomiting.
In March 2007, the U.S. FDA sent warning letters to twenty drug companies, instructing them to stop selling unapproved medications containing ergotamine tartrate for the treatment of migraine, including several popular ergotamine and belladonna combination drugs previously marketed for migraine prevention. FDA-approved ergotamine drugs were not affected by the action.
Fast-acting formulations of ergot derivatives are available in pills that dissolve under the tongue (Ergomar), injections (DHE-45), and nasal sprays (Migranal).
Ergot derivatives can cause troublesome side effects, including nausea, abdominal cramps, dizziness, and dry mouth. Like opioids, frequent use of ergot derivatives results in increased tolerance and physical dependence on the drug. Too much of the drug can also trigger rebound or medication overuse headaches. When ergot derivatives are prescribed, they should be taken no more frequently than twice a week.
Because these drugs cause blood vessel constriction, they can also cause a condition known as peripheral vasospasm, which can restrict arterial blood flow and cause ischemia (tissue death) and potentially gangrene. Signs of this less common but potentially serious side effect include leg cramps and coldness, numbness, or pain in the hands or feet.
Dexamethasone is a corticosteroid that is administered intravenously to treat intractable migraine (i.e., migraine lasting longer than seventy-two hours). While several published case reports note the drug's efficacy, clinical trials on the drug have found no significant benefits. Further research is needed to see if corticosteroids have a role in migraine care.
If you take triptans, you should not take ergot derivatives, as the combination can cause a serious drug interaction. And if you are a woman who is pregnant or nursing, or if you have a history of heart disease, severe high blood pressure, angina, coronary artery disease (CAD), reduced liver or kidney function, or peripheral vascular disease, you should not take ergot derivatives. People with mild high blood pressure or hyperthyroidism should consult with their doctor before taking these drugs.
Ergot derivatives are often combined with other medications to increase their efficacy and reduce side effects. Ergotamine and caffeine combinations are available in generic form and under the brand names Cafergot and Migergot. These formulations are available in pill or suppository form. Suppositories may be preferred when nausea and vomiting are severe.
