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Intranasal Dihydroergotamine

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Intranasal Dihydroergotamine, Migranal, Atzumi Nasal Powder Inhaler

  • See Also
  1. Dihydroergotamine
  2. Migraine Abortive Management
  • Indications
  1. Migraine Abortive Management
    1. Rarely used in modern U.S. Migraine Management (largely replaced by Triptans)
  • Contraindications
  1. See Dihydroergotamine
  • Mechanism
  1. See Dihydroergotamine
  • Medications
  • Intranasal Dihydroergotamine
  1. Migranal Nasal Spray: 0.5 mg per spray
  2. Atzumi Nasal Powder Inhaler 5.2 mg/device
  • Precautions
  1. Give first dose in health care facility in those with Cardiovascular Risk Factors
  2. Ergotamines have been replaced by Triptans for multiple reasons
    1. Low oral Bioavailability
    2. High risk for Medication Overuse Headache
    3. Common associated Nausea and Vomiting
    4. Serious adverse Drug Interaction risk
  • Dosing
  • Adults
  1. Migranal
    1. Prepare sprayer by inserting ampule and prime pump (4 squeezes before first use)
    2. Use one spray each nostril
    3. May repeat x1 after 15 minutes (Total dose = 2mg)
    4. Maximum
      1. Day: 6 sprays (3 mg/day)
      2. Weekly: Twice per week or 8 sprays/week (4 mg/week)
  2. Atzumi Nasal Powder Inhaler
    1. Setup device (no priming needed)
    2. Spray one device into 1 nostril
    3. May repeat 1 spray into the same single nostril after 1 hour
    4. Maximum
      1. Day: 2 sprays (10.4 mg/day)
      2. Weekly: 4 dose maximum
      3. Monthly: 12 dose maximum
  • Adverse Effects
  1. Rhinitis
  2. Nausea
  3. Taste perversion
  • Safety
  1. Avoid in Pregnancy (Pregnancy Category X)
  2. Avoid in Lactation
  • Efficacy
  1. Significant Migraine response in 30 minutes
    1. Migranal: 70%
    2. Placebo: 28%
  2. Reference
    1. Gallagher (1996) Arch Neurol 53:1285-91 [PubMed]
  3. Advantages
    1. Lasts longer than intranasal Imitrex
    2. Rebound Headache less common than Imitrex
      1. Rebound HeadacheIncidence: 15% within 24 hours
    3. Less expensive than Intranasal Imitrex ($16/dose)
  4. Disadvantages
    1. Does not work as fast as intranasal Imitrex
    2. More complicated to use than intranasal Imitrex
  • Resources
  1. Intranasal Dihydroergotamine (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=977de209-c53a-4cb4-9f3f-1e850600a9dc