Repetitive intravenous DHE in the treatment of refractory headache

We analyzed retrospectively the data for 300 patients with refractory headache who were treated with dihydroergotamine (DHE) at the Comprehensive Headache Center at Germantown Hospital. The patients had either chronic daily headache (with drug rebound -216, without rebound -42), short-duration headache (18), or cluster headache (24). Treatment consisted of withdrawal of overused medications (usually analgesics and ergots), repetitive IV administration of DHE, and use of metoclopramide and prophylactic medications, together with educational and psychological support. Overall, 91% (range, 86% to 100%) of the patients became headache-free, usually within 2 to 3 days. The average duration of hospitalization was 7.4 days. Side effects, reported in 157 (52%) of the patients, consisted primarily of nausea (32%), tightness and burning (8%), leg cramps (7%), vomiting (6%), and increased blood pressure (5%). The side effects generally resolved spontaneously or with adjustment of the DHE dose and/or adjunct medication, and necessitated withdrawal of therapy in only 2 patients (1 with drug-related claudication; 1 with somatic complaints of uncertain origin). We conclude that a regimen of repetitive intravenous DHE and metoclopramide can provide rapid relief of chronic intractable headache, and can ameliorate the effects of analgesic and ergot withdrawal in patients with chronic daily headache and rebound associated with overuse of these drugs.

[Generalized brain edema and cerebral infarct in ergotamine abuse: imaging by computerized tomography, magnetic resonance tomography and angiography]

Abuse of ergotamine can release a generalised brain edema and brain infarctions. This can be visualized by CT, MR and angiography. The reason, however, can only be found in the patients history.

[Complications following preventive treatment of thromboembolism with Dihydergot-heparin]

The observation of two cases of ergotism after administration of dihydroergotamine (Dihydergot-heparin (DHEH], led to review of the literature concerning documentation of the use of this drug in postoperative thromboembolism prophylaxis and the incidence of complications to this treatment. DHE is supposed to exert a selective constrictive effect on veins. There are now, however, numerous reports of ergotism because of arterial spasm. Some authors find better thromboembolic prophylactic effect, when DHE is used in combination with low-dose heparin (LDH) while others cannot show any advantages of using this drug. Several trials show that the best method for thromboembolic prophylaxis consists of graduated supportive stockings (TED) combined with LDH. The use of DHE in postoperative thromboembolism prophylaxis cannot be recommended. TED combined with LDH should be preferred.

[Complications of thromboembolic prophylaxis with heparin-dihydroergotamine]

In a prospective study the complications of Heparin-Dihydroergotamine (HDHE) [2,500 units Heparin + 0.5 mg DHE] s c. twice daily as thromboembolic prophylaxis have been studied in patients undergoing a lumbar disc operation. During a two year period 616 patients were operated, 47 patients had to be excluded, 107 patients did not receive HDHE desired by the surgeon; 462 patients received HDHE as described in the protocol. Because the distribution of age, sex, duration of hospitalisation of the 107 patients without HDHE is the same as in the HDHE group, this group can be used as control group. Increased intraoperative bleeding--written down in the operation report--66 patients (14.3%) in HDHE group and 6 patients (5.6%) in the control group. There is no statistic significance between the both groups in superficial and deep wound hematomas, deep vein thromboses or pulmonary embolism. In the HDHE group two death appears. Both patients [a 37 year old, asymptomatic woman and a 65 year old man with mild ischemic symptoms 11 months prior to operation] died because of an acute myocardial infarction. The clinical course and the missing of stenosis or occlusion at autopsy let us think at the possibility of coronary arterial spasm, presumably caused by DHE, as the cause of myocardial infarction. We suggest not to apply HDHE to patients with coronary artery heart disease or with atypical thoracic pain.

Fixed combinations of low-molecular weight or unfractionated heparin plus dihydroergotamine in the prevention of postoperative deep vein thrombosis

A prospective, double-blind, randomized, controlled clinical trial compared the efficacy and safety of fixed combinations of low-molecular weight heparin or standard unfractionated heparin plus dihydroergotamine mesylate in the prevention of deep vein thrombosis in high-risk patients undergoing elective major abdominal surgery. Two hundred patients, with a mean age of 66.6 years and almost half with malignancy, were allocated to receive either 5,000 IU unfractionated heparin plus 0.5 mg dihydroergotamine mesylate twice daily or 1,500 IU low-molecular weight heparin plus 0.5 mg dihydroergotamine mesylate once daily together with one placebo injection per day. Treatment was commenced 2 hours preoperatively and continued for at least 7 days. The incidence of deep vein thrombosis, determined by radiolabelled fibrinogen uptake and phlebography, was 11 percent in the unfractionated heparin plus dihydroergotamine mesylate group and 11.4 percent in the low-molecular weight heparin and dihydroergotamine mesylate group. Neither these figures nor those for major proximal thrombi proved significantly different. Of the four parameters used to assess hemorrhagic complications, only the decrease in postoperative hemoglobin levels in the low-molecular weight and dihydroergotamine mesylate group reached statistical significance. These results indicate that once-daily prophylaxis with a combination of low-molecular weight heparin and dihydroergotamine is safe, effective, and convenient in high-risk patients undergoing major abdominal surgery.

Ergotism as a consequence of thromboembolic prophylaxis

Vasospasm related to ergot intoxication is unusual. The authors report the case of 15-year-old boy who developed vasospasm necessitating amputation, due to an ergot derivative prescribed for thromboembolic prophylaxis. The importance of prompt angiographic recognition and therapy is stressed.

Control of therapy with microcirculatory and phlebotropically active drugs in patients with congenital and acquired venous insufficiency

During the treatment of two patients with Klippel-Trenaunay syndrome interesting observations of the efficacy and the side effects of DHE were made. This led to the decision to carry out a validity study in 12 patients suffering from chronic venous insufficiency (CVI). The patients were treated with 0.25 mg or 0.5 DHE intravenously, and after that with 7.5 mg orally for one week. Before and after treatment measurements of venous capacity, microcirculatory parameters and rheological parameters were performed. Following the i.v. injection of 0.25 to 0.5 mg DHE the venous capacity decreased significantly in a dose-dependent way. The flow of erythrocytes in capillaries measured under resting condition was significantly lower and peak flow of reactive hyperemia decreased. No relation was found between the dose of DHE administered and the particular side effects (stomach trouble, increase in diastolic blood pressure) in 2 of the 12 patients. After oral treatment patients showed signs of subjective improvement of their complaints. On the basis of the results, the validity of non-invasive angiological tests is discussed.

A prospective randomized trial of low molecular weight heparin-DHE and conventional heparin-DHE (with acenocoumarol) in patients undergoing gynaecological surgery

The antithromboembolic efficacy of once a day low molecular weight heparin in fixed combination with dihydroergotamine (LMWH-DHE) was compared with conventional heparin-DHE in combination with Acenocoumarol (heparin-DHE/A) in 191 patients undergoing gynaecological surgery. LMWH-DHE proved equally effective in preventing thromboembolic complications, with a similar incidence of postoperative bleeding and side effects. Deep vein thrombosis occurred once in each group and one non-fatal pulmonary embolism occurred in the LMWH-DHE group. The main advantage of LMWH-DHE was significantly better patient acceptance of the single daily subcutaneous injection as compared with the two injections of conventional heparin-DHE (P = 0.02). On the other hand, LMWH-DHE was associated with significantly increased incidence of intraoperative bleeding (P less than 0.02). The bleeding did not, however, cause any clinical problems. Discontinuation of therapy due to bleeding or pain at the site of injection occurred three times in each group. We consider the use of LMWH-DHE to be an attractive, economic and safe method of thromboembolic prophylaxis.

[Ergotism of the lower extremities resulting from thrombosis prevention using DHE-heparin. An angiographic follow-up study]

Today ergotism is becoming more and more important as a complication in the treatment of migraine headache or thrombosis prophylaxis with DHE heparin. Although complete recovery is seldom reported in the current literature, in our case it was possible to resolve a spasm of the left lower limb completely by early diagnosis and adequate pharmacological treatment. The case was well documented by serial angiography.

Bilateral upper extremity ischemia after administration of dihydroergotamine-heparin for prophylaxis of deep venous thrombosis

Prolonged arterial spasm as a complication of ergot-containing medications has been reported since antiquity. This article describes our experience with a patient who had severe bilateral arterial spasm in the upper extremities 6 days after the initiation of a regimen of dihydroergotamine and heparin for prophylaxis against deep venous thrombosis. The spasm was refractory to oral calcium channel blocking agents and direct intraarterial infusion of tolazoline (Priscoline). However, intraarterial nitroglycerin produced a prompt and dramatic improvement in symptoms and in physical and arteriographic findings. This experience suggests that intraarterial nitroglycerin may be an appropriate first choice for ergot-induced arterial spasm.

Refractory vasospasm occurring in a trauma patient receiving dihydroergotamine and heparin

A case of severe vasospasm producing ischemia associated with the administration of dihydroergotamine and heparin for prophylaxis of deep venous thrombosis is presented. We feel that the intensity of the vasospasm was related to the ergot in combination with the use of pressors and the presence of an operative site contiguous to the spastic artery. Based on our experience and a review of the world's literature, we feel that risk of vasospasm in trauma patients outweighs the potential additional benefit of this combination of drugs over heparin prophylaxis alone.

Combined low-dose acetylsalicylic acid and dihydroergotamine in migraine prophylaxis. A double-blind, placebo-controlled crossover study

The efficacy of the combination of dihydroergotamine (10 mg) with acetylsalicylic acid (80 mg) (DHE + ASA) in the prophylaxis of migraine was studied in a double-blind, placebo-controlled crossover trial (8 weeks twice). Of 45 patients who entered the study, 38 completed it. The number of attacks was significantly (p = 0.003) reduced during active treatment (11.5 +/- 6.2) compared with placebo (16.6 +/- 9.9). The mean duration, the mean severity, and the mean score for symptomatic acute medication of attacks did not differ significantly. The overall assessment made by the patients themselves was in favor of DHE + ASA (p = 0.001). These results indicate a moderately beneficial effect of the dihydroergotamine/low-dose acetylsalicylic acid combination in migraine prophylaxis.

Dihydroergotamine/heparin in the prevention of deep-vein thrombosis after total hip replacement. A controlled, prospective, randomized multicenter trial

In a randomized, double-blind, placebo-controlled multicenter trial, the efficacy and safety of dihydroergotamine mesylate/heparin sodium as a prophylactic agent for deep-vein thrombosis were evaluated in 148 patients who were forty years old or more and who underwent total hip replacement. The incidence of venographically proved postoperative deep-vein thrombosis was 52 per cent in the placebo group and 25 per cent in the dihydroergotamine mesylate/heparin sodium group (p = 0.002). Proximal thrombi developed in only 5 per cent and extensive thrombi, in only 10 per cent of the patients who received dihydroergotamine mesylate/heparin sodium. In contrast, proximal thrombi and extensive thrombi developed in 19 and 25 per cent, respectively, of the patients in the placebo group (p less than 0.05). Adverse reactions in the two groups did not differ significantly: in the treatment group they consisted primarily of hematoma at the site of injection (9 per cent), hematoma at the wound (5 per cent), and excessive postoperative bleeding, and in the placebo group there was hematoma at the site of injection (3 per cent). It was concluded that the combination agent dihydroergotamine mesylate/heparin sodium was effective and safe prophylaxis against deep-vein thrombosis for the patients who underwent total hip replacement in this study.

Dihydroergotamine in acute herpes simplex infections

The effect of the subcutaneous administration of 0.5 mL of dihydroergotamine mesylate (1 mg/mL) compared with that of 0.5 mL placebo on the course of an individual episode of herpes simplex infection in patients, who reported at least two other outbreaks in the previous 12 months, was examined by means of a double-blind randomized trial. Thirty-seven patients were entered into the trial. The dihydroergotamine-treated group experienced a shorter duration of the over-all attack until healed skin reappeared, with a shorter duration of both pain and oedema, than did the placebo-treated group. The relatively small number of patients, and the fact that testing in an animal model showed no effect of dihydroergotamine on herpes simplex, suggests that these results need to be treated with caution.