Dihydroergotamine affects spatial behavior and neurotransmission in the central nervous system of Wistar rats

INTRODUCTION

Dihydroergotamine (DHE) is a derivative of an ergot alkaloid used as an antimigraine medication. Nowadays, ergot alkaloids may still endanger the safety of humans and animals as food or medicine pollutants, but the outcomes of long-term DHE administration on the behaviour and neurotransmission remain undescribed.

MATERIAL AND METHODS

Adult male Wistar Albino Glaxo rats pre-treated orally with DHE for six weeks were investigated to assess the relationship between concentration of neurotransmitters and behavioural response. The behavioural effects of the drug administered at doses of either 30 µg/kg b.w. (group DHE30, n = 11) or 100 µg/kg b.w. per day (group DHE100, n = 10) were evaluated in the Morris Water Maze. It is known that monoaminergic neurotransmitters (serotonin, noradrenaline and dopamine) in some brain structures (prefrontal cortex, hippocampus, striatum, cerebellum, spinal cord) play a role in the control of cognitive and motor functions. The concentration of neurotransmitters was determined by High Performance Liquid Chromatography (HPLC).

RESULTS

Administration of DHE influenced neither the learning processes nor memory in rats. Nevertheless, an increased motor activity of the DHE-administered animals was observed in both the cued and non-cued behavioural tasks. In HPLC examination, changes in the concentration of monoaminergic neurotransmitters and their metabolites were noted in all tested structures, except for the hippocampus.

CONCLUSIONS

DHE is able to modulate noradrenergic, serotonergic and dopaminergic neurotransmission that may support the increase in locomotion.

What's new in the migraine attack treatment

This short review aims to give a focus on news in the migraine attack treatment and discusses the CGRP receptor antagonists (gepants), the 5-HT1F receptors agonists (ditans), the transcranial magnetic stimulation for the treatment of migraine attack with aura, innovative delivery systems for sumatriptan and the oral inhalation of dihydroergotamine.

Effects of a supratherapeutic dose of investigational orally inhaled dihydroergotamine (MAP0004) on QT interval: a randomized, double-blind, active- and placebo-controlled crossover study in healthy volunteers

BACKGROUND

MAP0004 is an orally inhaled investigational drug containing dihydroergotamine (DHE). Although DHE has been used for 60 years with no reported cardiac arrhythmias, a thorough QT study had not previously been performed with DHE.

OBJECTIVE

The objective of this study was to assess the effects of MAP0004 on the QT interval as required for regulatory approval of a new product.

METHODS

This randomized, double-blind, placebo-controlled, 3-period crossover study enrolled healthy volunteers. Subjects were assigned to receive, in randomized sequence, MAP0004 at a supratherapeutic dose (3-fold the clinically effective dose) (3.0 mg), moxifloxacin 400 mg, or inactive vehicle, each administered with 1 placebo capsule. Triplicate ECGs were performed continuously at baseline (day 0), before dosing, and over 24 hours after dosing in each treatment period. The effect on the QT interval was assessed using the Fridericia (QTcF) and individualized (QTcI) correction formulas.

RESULTS

Fifty-four healthy adults (20 men, 34 women; mean age, 28 years) completed the trial and had measurable plasma levels of DHE after MAP0004 administration. The largest observed mean difference in QTcI between MAP0004 and placebo was 0.08 msec, and the largest 1-sided 95% upper confidence bound was 2.24 msec, both at 30 minutes after dosing. In contrast, moxifloxacin increased the mean QTcI between 9.57 and 11.28 msec relative to placebo, with a 1-sided lower 95% CL between 7.23 and 8.96 msec, confirming that the assay sensitivity was sufficient to detect MAP0004-related effects. Nausea (27.8%) was common following MAP0004 administration but apparently did not influence the QTc interval.

CONCLUSIONS

A supratherapeutic dose of MAP0004 was not associated with prolonged QTc intervals. At the proposed clinical dose (1.0 mg), MAP0004 is unlikely to affect the QT interval. MAP0004 and its primary metabolite showed no evidence for prolongation of the QTc interval in healthy subjects according to the criteria required from regulatory agencies. ClinicalTrials.gov identifier: NCT01191723.

Sumatriptan (intranasal route of administration) for acute migraine attacks in adults

BACKGROUND

Migraine is a highly disabling condition for the individual and also has wide-reaching implications for society, healthcare services, and the economy. Sumatriptan is an abortive medication for migraine attacks, belonging to the triptan family. Intranasal administration may be preferable to oral for individuals experiencing nausea and/or vomiting, although it is primarily absorbed in the gut, not the nasal mucosa.

OBJECTIVES

To determine the efficacy and tolerability of intranasal sumatriptan compared to placebo and other active interventions in the treatment of acute migraine attacks in adults.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, online databases, and reference lists for studies through 13 October 2011.

SELECTION CRITERIA

We included randomised, double-blind, placebo- and/or active-controlled studies using intranasal sumatriptan to treat a migraine headache episode, with at least 10 participants per treatment arm.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate relative risk (or 'risk ratio') and numbers needed to treat to benefit (NNT) or harm (NNH) compared to placebo or a different active treatment.

MAIN RESULTS

Twelve studies (4755 participants) compared intranasal sumatriptan with placebo or an active comparator. Most of the data were for the 10 mg and 20 mg doses. Sumatriptan surpassed placebo for all efficacy outcomes. For sumatriptan 10 mg versus placebo the NNTs were 7.3, 7.4, and 5.5 for pain-free at two hours, and headache relief at one and two hours, respectively. For sumatriptan 20 mg versus placebo the NNTs were 4.7, 4.9, and 3.5, respectively, for the same outcomes. The 20 mg dose was significantly better than the 10 mg dose for each of these three primary efficacy outcomes.Relief of headache-associated symptoms, including nausea, photophobia, and phonophobia, was greater with sumatriptan than with placebo, and use of rescue medication was lower with sumatriptan than placebo. For the most part, adverse events were transient and mild and were more common with sumatriptan than placebo.Direct comparison of sumatriptan with active treatments was limited to two studies, one comparing sumatriptan 20 mg and dihydroergotamine (DHE) 1 mg, and one comparing sumatriptan 20 mg with rizatriptan 10 mg.

AUTHORS' CONCLUSIONS

Intranasal sumatriptan is effective as an abortive treatment for acute migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events compared with placebo.

MAP0004, orally inhaled dihydroergotamine for acute treatment of migraine: efficacy of early and late treatments

OBJECTIVE

To evaluate the efficacy of MAP0004, an orally inhaled dihydroergotamine, for acute treatment of migraine when administered at various time points from within 1 hour to more than 8 hours after migraine onset.

PATIENTS AND METHODS

This post hoc subanalysis was conducted using data from 902 patients enrolled in a randomized, double-blind, placebo-controlled, 2-arm, phase 3, multicenter study conducted from July 14, 2008, through March 23, 2009. End points were 2-hour pain relief and pain-free rates in patients who treated a migraine in ≤1 hour, from >1 hour to ≤4 hours, from >4 to ≤8 hours, or in >8 hours after onset of migraine, given that patients may be unwilling or unable to initiate treatment at headache inception.

RESULTS

Treatment with MAP0004 was significantly more effective than placebo in relieving pain at all treatment points (≤1 hour after start of migraine: 66% [74/112] for MAP0004 vs 41% [48/118] for placebo, P<.001; >1 to ≤4 hours: 60% [91/153] vs 35% [58/168], P<.001; >4 to ≤8 hours: 53% [36/68] vs 30% [16/54], P=.008; and >8 hours: 48% [25/52] vs 24% [11/46], P=.007). Pain-free rates were also significantly higher with MAP0004 than placebo for treatment within 8 hours after migraine onset (≤1 hour: 38% [43/112] for MAP0004 vs 13% [15/118] for placebo, P<.001; >1 to ≤4 hours: 28% [43/153] vs 10% [17/168], P<.001; >4 to ≤8 hours: 22% [15/68] vs 7% [4/54], P<.025) but not at >8 hours (19% [10/52] vs 9% [4/46], P=.106).

CONCLUSION

This post hoc subanalysis shows that MAP0004 was effective in treating migraine irrespective of the time of treatment, even more than 8 hours after onset of migraine pain.

Meeting acute migraine treatment needs through novel treatment formulations

Migraineurs often do not use acute migraine-specific medications. Patient-reported satisfaction with triptans is modest. Patients are generally interested in obtaining more rapid and complete symptom relief. The role of trigeminal vascular activation may explain why some patients fail to respond to current treatment. Novel formulations of currently available acute migraine treatments have been developed, with improved clinical outcomes, response times, and pain-free rates. Currently available effective, novel, acute migraine therapies include needle-free injectable sumatriptan and effervescent diclofenac. Orally inhaled dihydroergotamine is a new treatment modality. These novel formulations may help patients achieve desirable outcomes, including faster and more complete relief, more consistent response, and improved drug tolerability.

Randomized, double-blind, placebo-controlled study of the safety, tolerability and pharmacokinetics of MAP0004 (orally-inhaled DHE) in adult asthmatics

BACKGROUND

MAP0004 (a proprietary formulation of dihydroergotamine mesylate [DHE]) for inhaled delivery is being developed for acute migraine treatment. Because asthma and migraine often occur as co-morbid conditions, it is considered important to study the safety of MAP0004 in a population of asthmatic adults and to confirm that the pharmacokinetics of DHE, when inhaled by asthmatic subjects, were comparable to a population of healthy volunteers. The safety, tolerability, and pharmacokinetics of orally-inhaled MAP0004 administered by the Tempo inhaler were studied in adult asthmatics.

SCOPE

This was a randomized, double-blind, placebo-controlled study of two doses of inhaled MAP0004. Eligible subjects were randomized in a 2 : 1 ratio to MAP0004 or placebo and observed for 4 h after each dose. Pharmacokinetic parameters were determined pre-dose and up to 36 h post-dose.

FINDINGS

Among 19 subjects, geometric mean AUC(0-36) was 6754 pg.h/mL and geometric mean AUC(0-inf) was 7483 pg.h/mL. Geometric mean t(max) was 9.6 min, geometric mean C(max) was 3174 pg/mL, and geometric mean t((1/2)) was 9.5 h. Overall, 13 of 19 (68%) subjects reported at least one adverse event, most commonly nausea, vomiting, dysgeusia, and headache.

CONCLUSION

MAP0004 results in rapid and efficient systemic absorption in asthmatic subjects. Systemic DHE concentrations were similar to those previously reported in healthy subjects, and no clinically relevant safety issues were observed. While this small study was suitable for pharmacokinetic analysis and conclusions, MAP0004 use in migraineurs with concomitant stable asthma should be supported by larger studies of longer duration to confirm that it does not present additional safety risks compared to non-asthmatic migraineurs.

Acute treatment of paediatric migraine: a meta-analysis of efficacy

AIM

To undertake a meta-analysis of all randomised controlled trials (RCTs) on the acute pharmacologic treatment of children and adolescents with migraine headache.

METHODS

In total, 139 abstracts of clinical trials specific to the acute treatment of paediatric migraine were appraised. Inclusion criteria required clinical trials to be randomised, blinded, placebo-controlled studies with comparable endpoints. Non- English language publications were excluded. 11 clinical trials qualified for inclusion in the final meta-analysis. Two endpoints were analysed: the proportion of patients with (1) headache relief, and (2) complete pain relief, 2 h post-treatment.

RESULTS

The following medications were included in the analysis: acetaminophen (n = 1), ibuprofen (n = 2), sumatriptan (n = 5), zolmitriptan (n = 1), rizatriptan (n = 2) and dihydroergotamine (n = 1). Results are expressed as a relative benefit (RB) conferred over placebo and the number needed to treat (NNT). Only ibuprofen and sumatriptan provided a statistically significant relative efficacy in comparison with placebo. Two hours post-treatment, ibuprofen was associated with an RB 1.50 (95% CI 1.15-1.95) in the generation of headache relief (NNT 2.4) and RB 1.92 (95% CI 1.28-2.86) in the production of complete pain relief (NNT 4.9). Sumatriptan rendered an RB 1.26 (95% CI 1.13-1.41) in headache relief (NNT 7.4) and an RB 1.56 (95% CI 1.26-1.93) in the production of complete pain relief (NNT 6.9).

CONCLUSION

Despite the pharmacological options for the management of acute migraine, few RCTs in the paediatric population exist. Composite data demonstrate that only ibuprofen and sumatriptan are significantly more effective than placebo in the generation of headache relief in children and adolescents.

Dihydroergotamine for Early and Late Treatment of Migraine With Cutaneous Allodynia: An Open-Label Pilot Trial

OBJECTIVE

To explore whether dihydroergotamine (D.H.E. 45) is equally effective and safe for migraine with allodynia, when administered either early or late in an attack.

BACKGROUND

Central sensitization may account for the extracranial tenderness and cutaneous allodynia that can occur with migraine. Once allodynia is established, triptans are less effective. Dihydroergotamine is often effective for patients whose refractory headaches have failed prior triptan therapy.

METHODS

In this single-center, open-label pilot trial, patients with episodic migraine associated with cutaneous allodynia were treated on 2 occasions with dihydroergotamine 1.0 mg intramuscularly. One attack was treated within 2 hours (early) and a second attack at 4 hours (late) after the onset of throbbing pain. Headache pain and any associated symptoms, subjective cutaneous allodynia, and mechanical (brush) allodynia were assessed. All data were analyzed using the Fisher's exact test.

RESULTS

Thirteen patients met the entry criteria; however, data from only 9 patients, those who completed treatment for 2 migraine attacks, were used to evaluate the efficacy and safety of dihydroergotamine. Whether they took dihydroergotamine early or late in the attack, most patients (>55%) had headache relief within 2 hours, and at least 44% of patients achieved headache-free status by 8 hours postdose. Subjective cutaneous allodynia started to decline after 30 minutes postdose in the early treated group and after 120 minutes postdose in the late-treated group. Brush allodynia began to decline after 15 minutes postdose in the early treated group and after 90 minutes postdose in the late-treated group. Six of 9 patients (67%) reported at least 1 adverse event.

CONCLUSIONS

The results of this pilot trial provide proof of concept for the headache-relief benefit of dihydroergotamine in patients with migraine headache and allodynia. A large, placebo-controlled trial of dihydroergotamine in allodynic patients is warranted.

Repetitive dihydroergotamine nasal spray for treatment of refractory headaches: an open-label pilot study

OBJECTIVE

To evaluate the safety and efficacy of a repetitive intranasal (IN) dihydroergotamine (DHE) burst protocol for treatment of refractory headaches.

RESEARCH DESIGN AND METHODS

Patients with refractory headaches were enrolled in a prospective, open-label, pilot study. Patients were instructed to self-administer IN DHE every 8 hours for 3 days; each IN DHE dose consisted of one 0.5-mg spray in each nostril that was repeated 15 minutes later, for a total of 2.0 mg DHE per dose. Follow-up visits were scheduled approximately 3 weeks later.

MAIN OUTCOME MEASURES

Efficacy and safety measurements were collected during patient interviews. Primary efficacy measures were the change in headache frequency, duration, and severity (rated from 0 [none] to 5 [extremely severe]) between the initial and follow-up visits. Safety was assessed at the follow-up visits through the occurrence of adverse events (AEs).

RESULTS

Twenty-six patients were enrolled in the study. Follow-up visits were completed by 24 patients whose mean headache frequency at study entry was 6.6 d/wk. The IN DHE burst protocol was associated with significant mean decreases in headache frequency (2.6 d/wk, p < 0.001), duration (5.8 hours, p = 0.03), and severity (1.2 units, p < 0.001) between study entry and the follow-up visit. One patient discontinued IN DHE use early because of an AE (nasal stuffiness); two additional patients each reported one AE (fatigue and increased headache) that was attributed to IN DHE.

CONCLUSIONS

The results of this pilot study suggest that the IN DHE burst protocol may be an effective and safe treatment for refractory headaches; interpretation of these results is limited by the open-label, uncontrolled design and the small number of patients. The development of a double-blind, placebo-controlled study to further evaluate this treatment regimen is warranted.

Acute treatment of pediatric headache in the emergency department and inpatient settings

Migraine headache can be debilitating. If initiated early, aggressive management may prevent severe disability and failure at school. It must be noted that treatments available for use for acute migraine headache in children and adolescents are off-label. Their use is widespread, but double-blind, placebo-controlled studies are still unavailable for this age group.

Parenteral Dihydroergotamine for Acute Migraine Headache: A Systematic Review of the Literature

STUDY OBJECTIVE

Many therapies are used in the treatment of acute migraine headache, with little agreement on effectiveness. This systematic review is designed to determine the effectiveness of parenteral dihydroergotamine in reducing pain, nausea, and relapse for episodes of acute migraine in adults.

METHODS

Randomized controlled trials were identified using MEDLINE, EMBASE, other computerized databases, hand searching, bibliographies, and contacts with industry and authors. Studies in which dihydroergotamine (alone or in combination with an antiemetic) was compared with placebo or any other common migraine therapy were considered. Relevance, inclusion, and study quality were assessed independently by 2 reviewers.

RESULTS

From 281 potentially relevant abstracts, 11 studies met the inclusion criteria. Solitary dihydroergotamine use was compared to sumatriptan and phenothiazines in 3 studies; results failed to demonstrate a significant benefit of dihydroergotamine over these therapies. In 8 combination treatment studies, heterogeneity in study methodology prevented statistical pooling. However, dihydroergotamine administered with an antiemetic was as effective as or more effective than meperidine, valproate, or ketorolac across all pain, nausea, and relapse outcomes reported in all studies.

CONCLUSION

This evidence suggests that dihydroergotamine is not as effective as sumatriptan or phenothiazines as a single agent for treatment of acute migraine headache; however, when administered with an antiemetic, dihydroergotamine appears to be as effective as opiates, ketorolac, or valproate. Given its nonnarcotic properties, parenteral dihydroergotamine combined with an antiemetic should be considered as effective initial therapy in clinical practice.

Traitement médicamenteux de l’accès migraineux chez l’enfant

Migraine, according to the criteria of the International Headache Society, occurs in about 5 to 10% of children. Management of acute headache is only one of the parts of the treatment, along with identification of migraine precipitants, adjustments in lifestyle, and when necessary the use of preventive therapy, which can include non pharmacologic (relaxation or biofeedback) or pharmacologic treatment. In the acute migraine attack, a single dose of either ibuprofen 10 mg/kg or paracetamol 15 mg/kg has been shown to be effective, with only a few adverse effects. In severe migraine attacks, dihydroergotamine mesylate administered orally (20 to 40 microg/kg) or intravenously (maximum 1 mg/day) may be helpful, but there have been no large placebo-controlled trials of this treatment. Among the different triptans, it is the sumatriptan nasal spray whose efficacy has been best demonstrated. The most frequent adverse event is transitory unpleasant taste.

Efficacy of intravenous diphenhydramine versus intravenous DHE-45 in the treatment of severe migraine headache

This study was conducted to compare the efficacy of intravenous diphenhydramine with dihydroergotamine mesylate (DHE-45; Novartis International AG, Switzerland) in the treatment of severe, refractory, migraine headache. A retrospective review was conducted to include eighty randomly chosen patients who were admitted to the Michigan Head Pain & Neurological Institute's inpatient program at Chelsea Community Hospital. Patients had received nine doses of diphenhydramine or nine doses of DHE-45 during a 3-day period. Patients receiving DHE-45 also received metoclopramide (Reglan; AH Robins Company, Inc., Richmond, VA) as prophylaxis for nausea. Demographics, headache diagnosis, psychiatric discharge diagnoses, abortive medications, and adverse events were recorded and assessed.

The PROMISE study: PROphylaxis of MIgraine with SEglor (dihydroergotamine mesilate) in French primary care

INTRODUCTION

Seglor capsules, a unique modified-release formulation of dihydroergotamine mesilate, have long been in clinical use in France for migraine prophylaxis. The aim of the PROMISE (PROphylaxis of MIgraine with SEglor) study was to establish the efficacy and tolerability of Seglor in the prevention of migraine in a general practice setting.

METHODS

The PROMISE study was a double blind, placebo-controlled, parallel-group study carried out in primary care practice. It included 363 migraine patients treated with Seglor or placebo for 5 months after a 1-month placebo run-in phase.

RESULTS

Migraine attack frequency (primary efficacy criterion) decreased markedly in the two treatment groups so that the difference in favour of Seglor did not reach statistical significance. However, most secondary outcome measures (duration of single attack, total duration of attacks over 1 month, consumption of mild opiate analgesics, subjective improvement) improved to a significantly greater degree in patients receiving Seglor than in those receiving placebo. In the 84.5% of patients who had impaired quality of life at entry, the percentage of reduction in attack frequency and most other efficacy measures showed significant improvement with Seglor. The safety profile for Seglor was comparable to that of placebo.

CONCLUSION

These results support the effectiveness of Seglor in patients with migraine-related quality-of-life impairment. The findings of the PROMISE study also suggest that patients' quality of life should be assessed systematically before initiating a preventive treatment for migraine.

Observations of the "carry-over effect" following successful termination of chronic migraine in the adolescent with short-term dihydroergotamine, dexamethasone and hydroxyzine: a pilot study

Chronic migraine management almost always requires daily oral preventative medication with potential adverse effects. Daily oral preventative therapy may also not be effective in terminating chronic migraine. Chronic central sensitisation caused by repetitive migraine attacks in a young person may lower the threshold for future migraine episodes leading to an intractable and debilitating disease course. The objective was to determine if short–term parenteral dihydroergotamine, dexamethasone and hydroxyzine can terminate chronic migraine and be followed by a continuous respite or conversion to a more benign episodic form without the need for daily oral preventative medication (“carry–over effect”). We treated ten patients, seven adolescents and three adults, with parenteral dihydroergotamine, dexamethasone and hydroxyzine given once a week for a maximum of three weeks. No oral preventative daily medication was administered. The setting was a private practice. Chronic migraine was terminated in all 7 adolescents. Their post–treatment course was converted to a more benign episodic migraine course and no adolescent required daily oral migraine preventative therapy for significantly long carry–over post–treatment observational periods. None of the three adult chronic migraine cases could be terminated satisfactorily as they all required daily oral preventative therapy. In the adolescent group only, this strategy terminated chronic migraine and resulted in a significant carry–over effect that appeared to favourably modify the long–term course without the need for daily pharmacological, potentially toxic, preventive therapy. Although this is a very small study, which requires confirmation by a larger controlled study, our data suggest a significant carryover effect in the young migraineur by administering short–term parenteral dihydroergotamine, dexamethasone and hydroxyzine.

Evaluation of a monthly coverage maximum (drug-specific quantity limit) on the 5-HT1 agonists (triptans) and dihydroergotamine nasal spray

BACKGROUND

Ensuring the appropriate use of migraine therapies is an important consideration for care providers, patients, employers, and managed care organizations (MCOs) because of the high cost of treatment for this fairly prevalent disabling disease. A review of utilization of serotonin 5-HT1 receptor agonists (triptans) in an MCO determined that about 24% of the patients who received triptan therapy exceeded the manufacturers. recommendations regarding the maximum daily dose and safe treatment guidelines in a 30-day period. An initiative was designed to manage the coverage of migraine abortive therapies with the anticipated outcome of decreasing potential misuse or overuse of the medications.

OBJECTIVE

The objective of this retrospective, observational study was to determine the impact of a monthly drug-specific milligram coverage maximum (quantity limit) on serotonin 5-HT1 receptor agonists (triptans) and dihydroergotamine (DHE) nasal spray on the utilization and costs of migraine care in an MCO with approximately 600000 covered members.

METHODS

A longitudinal, retrospective cohort analysis was conducted. All migraine-related services were analyzed, including outpatient medical visits, emergency department utilization, inpatient hospitalizations, and outpatient prescription drug use. The analysis was conducted using medical and pharmacy administrative claims. Analysis of data was performed for the period 12 months prior (October 1999 to September 2000) and 18 months postimplementation of the monthly drug-specific milligram coverage maximum (October 2000 through March 2002).

RESULTS

Imposition of a monthly coverage maximum for migraine-abortive therapies was associated with a 26.1% reduction in overall per- patient-per-month (PPPM) medical costs for migraine care, from US dollars 55.52 PPPM to US dollars 41.02 PPPM (P<0.01). Utilization of serotonin 5-HT1 receptor agonists and DHE nasal spray declined by 16.7%, from 0.18 prescriptions PPPM to 0.15 prescriptions PPPM (P=0.039), and direct drug costs declined by 28.8%, from US dollars 29.18 PPPM to US dollars 20.78 PPPM (P<0.001). Utilization and costs of outpatient and inpatient migraine-related medical services declined by 40% from US dollars 16.58 PPPM in the preperiod to US dollars 9.94 PPPM in the postperiod (P<0.001).

CONCLUSION

A monthly drug-specific milligram coverage maximum was associated with significant reduction in drug costs and utilization of serotonin 5-HT1 receptor agonists (triptans) and DHE nasal spray. Utilization and costs of migraine-related medical services also declined after implementation of the coverage maximum for triptans and DHE nasal spray. The monthly drug-specific milligram coverage maximum appeared to have been successful in managing utilization of triptans and DHE nasal spray, including reduction of overall costs of migraine-related medical services and direct drug costs.

Topical agents in the treatment of cluster headache

This article discusses topical intranasal medications in the treatment of cluster headache.

Modulation of cytochrome P450 metabolism by ergonovine and dihydroergotamine

This study investigated modulation of the cytochrome P450 3A (CYP3A4)-mediated metabolism of ergotamine (ET) by ergonovine and dihydroergotamine. Liver microsomes were prepared from rats treated i.p. for 4 d with: low (10 mM) or high (100 mM) levels of dexamethasone (DM10 and DM100), dihydroergotamine, ergonovine, or control. Cytochrome P450 activity was evaluated using ET and its isomers as substrate. Ergotamine was converted to its metabolites at rates of 0.385 or 0.535 (SE = 0.040) nM/microg protein/min when incubated with liver microsomes from DM10 or DM100 treated rats, respectively. These rates were higher than for rats on other treatments. Induction of CYP34A activity was not greater for ergonovine or dihydroergotamine treatments than for controls. Both ergonovine and dihydroergotamine treatments inhibited in vitro CYP3A4 activity in a dose dependent manner producing quadratic inhibition curves.

[The problems of migraine headache treatment]

The acute treatment and prophylaxis of migraine headache are discussed in this article. The medications for acute treatment, their doses, indications, contraindications and adverse effects are compared. The special attention for migraine headache prophylaxis is paid. The migraine diagnostic criteria and triggers of migraine headache are noted.

MT 300 ??? POZEN

MT 300 is an injectable formulation of dihydroergotamine mesylate (DHE; a serotonin 5-HT1 receptor agonist) that is being developed by POZEN for the acute treatment of migraine. POZEN intends to present MT 300 as a prefilled syringe that can be administered alone, or with an autoinjector. In September 2003, POZEN announced that it had formed a commercialisation agreement with Xcel Pharmaceuticals. Under the terms of the agreement Xcel will have exclusive rights to commercialise MT 300 in the United States, and will pay POZEN upfront and milestone payments, as well as royalties on future sales. In December 2002, POZEN submitted an NDA to the US FDA for MT 300 for the acute treatment of migraine with or without aura. In March 2003 POZEN announced that its New Drug Application (NDA) for MT 300 had been accepted for filing by the US FDA. Two phase III trials have been completed in the US. Both studies, the first involving 619 patients with migraine and the second (and final study) involving 550 patients with migraine, have produced promising results. POZEN received a US patent (6,495,535) with claims related to therapeutic packaging of dyhydroergotamine in a prefilled syringe. This is the first issued patent for MT 300. POZEN has multiple pending foreign patent applications. The patents have claims regarding liquid pharmaceutical compositions for the treatment of migraine, which contain concentrated dihydroergotamine.

Practical approaches to migraine management

Migraine is a recurrent clinical syndrome characterised by combinations of neurological, gastrointestinal and autonomic manifestations. The exact pathophysiological disturbances that occur with migraine have yet to be elucidated; however, cervico-trigemino-vascular dysfunctions appear to be the primary cause. Despite advances in the understanding of the pathophysiology of migraine and new effective treatment options, migraine remains an under-diagnosed, under-treated and poorly treated health condition. Most patients will unsuccessfully attempt to treat their headaches with over-the-counter medications. Few well designed, placebo-controlled studies are available to guide physicians in medication selection. Recently published evidence-based guidelines advocate migraine-specific drugs, such as serotonin 5-HT(1B/1D) agonists (the 'triptans') and dihydroergotamine mesylate, for patients experiencing moderate to severe migraine attacks. Additional headache attack therapy options include other ergotamine derivatives, phenothiazines, nonsteroidal anti-inflammatory agents and opioids. Preventative medication therapy is indicated for patients experiencing frequent and/or refractory attacks.

Haemodynamic effects of three doses of dihydroergotamine during spinal anaesthesia

We performed a randomized study comparing the haemodynamic effects of three doses of the vasopressor dihydroergotamine (DHE) (5, 10 and 15 microg x kg(-1)) in 30 ASA 1 and 2 patients, aged 53-87 yr, undergoing spinal anaesthesia. Non-invasive systolic arterial pressure (SAP), heart rate and central venous pressure (CVP) were recorded continuously for 25 min. Intravenous fluids were withheld during this period. All three doses of DHE reversed the lowering effects of spinal anaesthesia on SAP and CVP (P<0.0001), and these effects were smooth in onset and sustained. Whereas the lowest (5 microg x kg(-1)) dose restored SAP and CVP to near prespinal values, the higher (10 and 15 microg x kg(-1)) doses resulted in above-baseline increases in SAP of 7% and in CVP of 2.7 cm H2O (P<0.05). The haemodynamic profile of DHE makes it a useful agent for managing hypotension during spinal anaesthesia. A dose of 5-10 microg x kg(-1) is recommended.

Status migrainosus in children and adolescents

Data concerning status migrainosus in children and adolescents is sparse. The varied clinical presentations, diagnostic evaluation, and treatment modalities are discussed.

Ergotamine, dihydroergotamine: current uses and problems

In randomized clinical trials oral ergotamine was found superior to placebo but inferior to oral sumatriptan 100mg. In contrast rectal ergotamine was found to have higher efficacy (73% headache relief) than rectal sumatriptan (63% headache relief). Intranasal dihydroergotamine (DHE) was found superior to placebo but less effective than subcutaneous and intranasal sumatriptan. In general, the use of the more specific drugs, the triptans, causing less adverse events and being more effective, is preferable to the use of the ergotamine in the acute treatment of migraine. If ergotamine is to be used the rectal route is preferable. The rectal dose of ergotamine should be tailored to the individual patient. The intranasal dose of DHE , between 1 and 2 mg, should also be tailored to the individual patient. In order to avoid drug-induced headache ergotamine and DHE should not be used daily.

Newer intranasal migraine medications

Two new intranasal migraine medications, sumatriptan and dihydroergotamine mesylate, may offer specific advantages for patients who are seeking alternatives to various oral or parenteral migraine abortive therapies. Placebo-controlled clinical studies demonstrate that both intranasal forms are effective in relieving migraine headache pain, but published clinical trial information comparing these two intranasal medications with current abortive therapies is lacking. Both agents are generally well tolerated by patients, with the exception of mild, local adverse reactions of the nose and throat.

[Transformed migraine--chronic daily headache]

Transformed migraine is probably a common cause of chronic daily headache. The International Headache Society system of diagnostic classification of headache classifies headaches, not patients, and pays no attention to the long-term evolution of the patient's headache. We support the suggestion made by Silberstein et al. that transformed migraine should be used as a diagnostic label in patients suffering from chronic daily headache with "migrainous features" and a history of migraine. Since 1994, intravenous treatment with dihydroergotamine (DHE) has been used for these patients. Among 16 patients suffering from chronic daily headache which were treated with this drug in 1996, 10 patients reported complete relief of headache at discharge from the hospital, but only four patients experienced complete relief from headache for more than two weeks. We think that the most important treatment for these patients are medicament withdrawal, information, help and support so that patients may cope with their headache. Dihydroergotamine can help patients going through a withdrawal regime.

Bioavailability of intranasal formulations of dihydroergotamine

OBJECTIVE

A comparison of the pharmacokinetic properties of two novel intranasal preparations of dihydroergotamine mesilate (DHEM) with a commercially available intranasal preparation.

METHODS

Two intranasal formulations of DHEM in combination with randomly methylated beta-cyclodextrin (RAMEB) were prepared. Subsequently, in an open, randomised, crossover study in nine healthy volunteers, the following medication was administered: 2 mg DHEM/2% RAMEB nasal spray (= two puffs of 100 microliters); 2 mg DHEM/4 mg RAMEB nasal powder; 2 mg Diergo nasal spray (= four puffs of 125 microliters); 0.5 mg DHEM i.m., and 2 mg DHEM solution p.o.

RESULTS

No statistically significant differences were found in maximum plasma concentration (Cmax), time to reach Cmax (tmax), area under plasma concentration-time curve (AUC0-8 h), Frel(t = 8 h) and Cmax/AUC(t = 8 h) for the three intranasal preparations. The relative bioavailabilities of the DHEM/RAMEB nasal spray, the DHEM/RAMEB nasal powder and the commercially available DHEM nasal spray were 25%, 19% and 21%, respectively, in comparison with i.m. administration. The relative bioavailability after oral administration was 8%.

CONCLUSION

The pharmacokinetic properties of the novel intranasal preparations are not significantly different from the commercially available nasal spray. Advantages of the DHEM/RAMEB nasal spray are (1) less complicated handling, (2) reduction of the number of puffs and (3) a preference by the volunteers.

[A case of successful treatment of postprandial syncope with combined use of amezinium metilsulfate and dihydroergotamine mesylate]

An 86-year-old man, with a history of old cerebral hemorrhage, experienced repeated syncope after the meal. The blood pressure significantly decreased at the onset of syncope, and postprandial hypotension (PPH) was diagnosed. In order to treat the syncope, we administered midodrine hydrochloride, amezinium metilsulfate and dihydroergotamine mesylate. However, each of these drugs failed to prevent PPH and the syncope persisted. Then we administered a combination of amezinium metilsulfate and dihydroergotamine mesylate. This led to the disappearance of the syncope together with PPH. Combined use of these drugs should be further evaluated in the elderly patients with PPH.

Dihydroergotamine nasal spray in the treatment of acute migraine

OBJECTIVE

To evaluate the efficacy and safety of dihydroergotamine (DHE) nasal spray in patients suffering from common or classical migraine.

METHODS

In a double-blind parallel-group study, 52 outpatients with migraine were randomly allocated to DHE nasal spray or to placebo. Two puffs, one in each nostril, was taken as an initial dose (resulting in either 0.5 or 1 mg of DHE), followed by another puff (0.5 mg) after 30 and 60 minutes, if necessary, achieving a maximum dose of 2 mg for patients of the DHE 1-mg group or of 1.5 mg for patients of the 0.5-mg group. Four consecutive attacks were thus treated. The efficacy analysis was done for observed cases. The main outcome measure was reduction of the severity of the attacks.

RESULTS

No differences were observed in the migraine characteristics or the number of treatments of the patients from the different groups. Dihydroergotamine 1 mg tended to provide better relief than 0.5 mg, although the effect was not statistically significant. Patients taking DHE used less rescue medications, with a dose-dependent effect. Side effects were reported by four patients receiving DHE but not placebo. The tolerability of the drug was assessed as good by 94% of the patients.

CONCLUSION

These findings suggest that DHE nasal spray is well tolerated and has dose-dependent efficacy in migraine.

[Finger tip necroses after dihydroergotamine medication in limited systemic scleroderma]

A 78 year old women developed acute fingertip necrosis just a few days after starting dihydroergotamine. The lesions healed in 3 weeks after the medication was stopped. The patient had suffered from Raynaud syndrome for 5 years and limited systemic sclerosis was diagnosed during the necrotic episode. Advanced age and microangiopathies are contraindications to the use of ergot-containing preparations.

Double-blind, multicenter trial to compare the efficacy of intramuscular dihydroergotamine plus hydroxyzine versus intramuscular meperidine plus hydroxyzine for the emergency department treatment of acute migraine headache

STUDY OBJECTIVE

To evaluate intramuscular dihydroergotamine in direct comparison with opioid analgesia in the treatment of acute migraine headache.

METHODS

This was a prospective, multicenter, double-blind trial performed in the emergency departments of 11 general hospitals in the United States. One hundred seventy-one patients between the ages of 18 and 60 years who presented to the ED with acute migraine headache were enrolled. Patients were randomly assigned to receive either 1 mg dihydroergotamine (DHE) or 1.5 mg/kg meperidine (MEP) by intramuscular injection. The anti-nauseant hydroxyzine (H) was coadministered in both treatment groups.

RESULTS

One hundred fifty-six patients were evaluable. Treatment groups were comparable in sample size, demographics, and baseline measurements of headache pain. Reduction of headache pain as measured on a 100-mm visual analog scale was 41+/-33 mm (53.5% reduction) for the DHE group, and 45+/-30 mm (55.7% reduction) for the MEP group at 60 minutes after treatment (difference=2.2%; 95% confidence interval [CI] -10%, 14.5%; P=.81). Reduction in the severity of nausea and improvement in functional ability were similar between treatment groups. Central nervous system adverse events were less common in the DHE group (DHE 23.5% versus MEP 37.6%, difference-14.1%: 95% CI -28%, 0%). In particular, dizziness was reported less commonly with DHE than MEP (2% versus 15%, difference=-13%: 95% CI -21%, -5%).

CONCLUSION

In this prospective, double-blind trial of a convenience sample of ED patients randomly assigned to one of two treatment regimens, DHE and MEP were comparable therapies for acute migraine. The use of DHE avoids several problems associated with opioid analgesia, including dizziness.

Incidence and time course of cardiovascular side effects during spinal anesthesia after prophylactic administration of intravenous fluids or vasoconstrictors

We studied the time course of arterial hypotension and/or bradycardia requiring treatment during spinal anesthesia and compared the efficacy of i.v. fluid or vasoconstrictor administration for the prevention of these side effects. Patients (n = 1066) were randomly allocated to either a volume group (lactated Ringer's solution 15 mL/kg within 15 min before spinal anesthesia), a dihydroergotamine group (10 microg/kg i.m. 15 min before anesthesia), or a placebo group. All patients breathed O2-enriched air during spinal anesthesia (4 mL of plain 0.5% bupivacaine). With the placebo, there were side effects (mean incidence 22.9%) for up to 45 min after the start of anesthesia. Dihydroergotamine reduced the incidence of side effects, preferentially the late ones, more (mean incidence 11.8%) than fluid administration (mean incidence 16.9%), which was effective only during the first 15 min of anesthesia. Both heart rate and arterial pressure decreased within 15 min before the manifestation of symptoms. In a subgroup of patients, the incidence of side effects (8%) was greatly reduced by the intraoperative application of both sedatives and opioids. We conclude that cardiovascular side effects may occur at any time during spinal anesthesia. Fluid administration reduced the incidence of early events, but dihydroergotamine the late events.

IMPLICATIONS

Cardiovascular side effects requiring treatment occurred at any time during spinal anesthesia in our placebo-controlled study, regardless of the prophylactic regimen (fluid infusions versus dihydroergotamine).

Episodic cluster headache in a community: clinical features and treatment

OBJECTIVE

To study the clinical features and treatment given to episodic cluster headache patients in the Calgary region.

PATIENTS

Fifty-one (51) patients who responded to a media campaign, had previously been diagnosed by their family physicians, and who met International Headache Society (IHS) criteria for episodic cluster headache, formed the population for this study.

METHODS

The media campaign consisted of newspaper advertisements and radio publicity including physician interviews and talk shows. Patients were required to complete by 200-item questionnaire detailing clinical features and treatment of their cluster headache syndrome. Each patient was also interviewed by our research nurse for clarification and proper completion of questionnaire.

RESULTS

Fifty-one percent (51%) of our patients had short headache attacks lasting one hour or less. Almost one-half (45%) had three or four attacks per 24 hour period. Eighty-six percent (86%) had been referred to a neurologist. Sixty-nine percent (69%) had never used oxygen, but of those who had, one-half were still using it. Sumatriptan by injection had been tried by 26% of patients and of these, 93% considered it effective. Subcutaneous dihydroergotamine had been tried by 8%. For prophylaxis, 41% had tried methysergide, 31% prednisone, and 4% verapamil. Many patients had been prescribed migraine prophylactic drugs which are ineffective for cluster headache, and some had also undergone dental procedures or nasal and sinus surgeries.

CONCLUSIONS

Many cluster headache patients had not, to their knowledge, been prescribed or used the best symptomatic and prophylactic treatments for cluster headache. This should be addressed through educational programs and through making up-to-date information on the treatment of cluster headache readily available to physicians and patients.

In-patient treatment of chronic daily headache using dihydroergotamine: a long-term follow-up study

BACKGROUND

The treatment of chronic daily headache (CDH) due to medication overuse remains a common and difficult problem. For selected patients refractory to outpatient management we have used a treatment protocol using dihydroergotamine (DHE) as introduced by Raskin, during a brief (typically 48 hours) in-patient stay. While many studies have documented the short-term efficacy of the DHE protocol, there are limited data on its long-term effects. The purpose of this study was to evaluate quality of life, at three months post treatment and the present time.

METHODS

A retrospective chart review of all patients admitted for the DHE protocol from 1991 to 1996 revealed 174 cases. Of these, 132 patients were interviewed by phone.

RESULTS

The DHE protocol was shown to decrease headache frequency, severity, headache medication use, and absences from work both at three months and the time of interview.

CONCLUSION

This study has the largest patient base and the longest follow-up period for the use of DHE for CDH. The results confirm that the DHE protocol is helpful in breaking the cycle of CDH, although the long-term outcomes of this study are more conservative than other studies have reported.

Nasal absorption of dihydroergotamine from liquid and powder formulations in rabbits

Nasal drug delivery is an interesting route of administration for dihydroergotamine in migraine therapy. The currently available formulation contains dihydroergotamine at 4 mg/mL. For a nasal dose of 2 mg, a volume of 0.5 mL has to be administered, which sometimes leads to spillage of the formulation. The aim of the present study was to develop a nasal spray with a dihydroergotamine concentration of 10 mg/mL. To increase the solubility and stability of dihydroergotamine, randomly methylated beta-cyclodextrin was used. Liquid formulations and lyophilized powders of dihydroergotamine and randomly methylated beta-cyclodextrin were prepared. The liquid and powder formulations were compared by determining their pharmacokinetics and absolute bioavailability after nasal administration in rabbits. Nasal sprays were significantly more effective than drops in increasing the nasal bioavailability of dihydroergotamine, but the amount of randomly methylated beta-cyclodextrin in liquid sprays did not significantly alter the nasal absorption. For powder formulations, the dihydroergotamine absorption was dependent on the amount of methylated beta-cyclodextrin and powder volume, and the nasal bioavailability from the optimal powder was slightly, but not significantly, higher than that for liquids. In conclusion, the formulations investigated are a substantial improvement of the current commercial formulation, not only because the spray volume of the liquid spray can be reduced 2.5 times, but also because of the increased stability of liquid and powder sprays with randomly methylated-beta-cyclodextrin.

Continuous intravenous dihydroergotamine in the treatment of intractable headache

We reviewed data on 171 patients with refractory headache treated by continuous intravenous dihydroergotamine mesylate (i.v. DHE 45) and repetitive i.v. DHE and compared the efficacy of continuous i.v. DHE to repetitive i.v. DHE. One hundred (58.5%) patients had refractory chronic daily headache. Seventy-one (42%) had drug rebound headache. One hundred thirty-eight (81%) had refractory migraine without aura, and 28 (16%) had migraine with aura. Treatment consisted of either continuous i.v. DHE by infusion pump or repetitive i.v. DHE and withdrawal of excessively used analgesics, analgesic narcotics, ergotamines, or benzodiazepines. Eighty-nine (92.5%) patients treated with continuous i.v. DHE became headache-free; the majority, 62 (64.5%), within 3 days. Sixty-five (86.5%) patients treated by repetitive i.v. DHE became headache-free, 50 (66.5%) within three days. The average hospital stay for both treatment groups was 4 days. Twelve (12.5%) of the continuous group and 12 (16%) of the repetitive group were headache-free within 24 hours. The average length of time to become headache-free was similar for the two groups, 3.06 days for continuous i.v. DHE and 2.94 days for repetitive i.v. DHE. The most common side effect was nausea, followed by diarrhea, vomiting, and leg cramps. We conclude that DHE can be accurately and easily administered by continuous i.v. infusion pump, and that continuous i.v. DHE is a safe and efficacious mode of treatment producing results similar to repetitive i.v. DHE.

Dosing and administration of ergotamine tartrate and dihydroergotamine

Ergotamine tartrate (ET) and dihydroergotamine (DHE) are effective therapies for migraine and cluster headache. Optimal management with these agents must take several factors into account, including headache type and severity, associated symptoms, side effect potential, choice of dosage forms, and appropriate dosing. Oral ET is most appropriate for slowly evolving migraine without early onset nausea and/or vomiting, or for treatment of cluster headaches. Delivery of ET via rectal suppository (available only in combination with caffeine) is the most effective form, especially for patients with severe, rapid onset migraine accompanied by nausea and/or vomiting. Dihydroergotamine offers numerous benefits compared to ET, including a lower incidence of nausea and vomiting and headache recurrence, and a lack of rebound headache. Dihydroergotamine can be administered at any time during a migraine attack, including the aura. Intravenous administration provides rapid peak plasma levels and is the most effective form when a rapid effect is desired or for patients with intractable severe headache (status migrainosus, transformed migraine, rebound headache) and cluster headache. Intramuscular administration is effective for moderate to severe migraine with or without nausea and vomiting in the clinic. Intranasal delivery of DHE has shown significant promise for effective and convenient therapy in acute migraine and may be especially useful in the presence of nausea and/or vomiting. When used appropriately, DHE and ET provide clinicians with highly effective therapeutic options in a range of useful dosage forms for patients with migraine or cluster headaches.

Ergotamine tartrate and dihydroergotamine mesylate: safety profiles

Ergotamine tartrate (ET) and dihydroergotamine mesylate (DHE) have been widely and effectively used in the treatment of migraine for many decades, although few randomized, controlled clinical trials have been conducted with these compounds. To compare their safety profiles, the world literature on the two agents was surveyed. The results are summarized, along with a critical analysis of the strengths and limitations of the various sources of safety data (in vitro research, animal studies, Phase I and II studies, controlled clinical trials, and postmarketing surveillance). Significant pharmacologic and safety differences exist between ET and DHE. Dihydroergotamine mesylate is a less potent arterial vasoconstrictor than ET, although nearly equipotent as a venoconstrictor. It is a more potent alpha-adrenergic antagonist, but is much less emetic, has less effect on the uterus, and is not associated with rebound headache. Adverse effects associated with ET (which are often due to excessive dosage and/or chronic usage) include nausea, acroparesthesia, ischemia, habituation and overuse headache, and, rarely, overt ergotism. Reports of serious adverse effects following recommended doses of DHE are rare. As with most antimigraine drugs, the most frequent adverse effect with intravenous (i.v.) DHE is nausea; however, following intramuscular (i.m.) or intranasal (IN) administration, the incidence of nausea is low and concomitant administration of an antiemetic is not needed. In patients without contraindications, both DHE and ET are safe and effective when used in recommended doses. Nearly 50 years of clinical experience without major safety problems allows a high level of confidence in their clinical use.

Acute treatment of migraine with dihydroergotamine nasal spray. Dihydroergotamine Working Group

BACKGROUND

Despite the benefits of antimigraine medications for patients with migraines, parenteral administration of these drugs has certain disadvantages for at-home patient use.

OBJECTIVE

To examine the safety and efficacy of an intranasal spray formulation of dihydroergotamine mesylate in the treatment of migraines.

DESIGN

Double-blind, placebo-controlled trial in patients with migraines.

SETTING

Both private and institutional practice.

PATIENTS

A total of 348 patients with a diagnosis of migraine according to International Headache Society criteria were recruited; 310 patients qualified for participation.

INTERVENTIONS

Patients self-administered either 2 mg of dihydroergotamine mesylate, 3 mg of dihydroergotamine mesylate, or a placebo for each of 2 moderate to severe migraine headaches using a nasal spray apparatus.

MAIN OUTCOME MEASURES

Patients rated pain severity, functional ability, headache pain relief, incidence and severity of nausea, and the incidence of vomiting, photophobia, and phonophobia prior to treatment (base-line) and again at 0.5, 1, 2, 3, and 4 hours after treatment. Recurrences of headache pain within 24 hours were also noted.

RESULTS

Self-administration of dihydroergotamine resulted in significant increases in pain relief and functional ability and significant decreases in pain intensity and nausea compared with the placebo. Among patients treated with 2 mg of dihydroergotamine mesylate, 27% considered their migraine resolved (ie, no pain or mild pain) as early as 30 minutes after treatment. By 4 hours after treatment, 70% of these patients' headaches were resolved. Headache pain returned within 24 hours in only 14% of patients whose headaches had been resolved. No serious adverse effects of dihydroergotamine treatment were observed, and the adverse events that did occur were primarily related to the route of administration. The 2-mg dihydroergotamine mesylate dose provided slightly superior pain relief and was associated with fewer adverse events compared with the 3-mg dihydroergotamine mesylate dose.

CONCLUSIONS

The present results suggest that intranasal administration of dihydroergotamine represents an important new therapeutic option for migraine sufferers.