Headache Medicine Ergot-Derivative-Containing (Oral Route, Parenteral Route, Rectal Route) Precautions

Description and Brand Names

Drug information provided by: Merative, Micromedex®

Canadian Brand Name

Cafergot

Descriptions

Dihydroergotamine and ergotamine belong to the group of medicines known as ergot alkaloids. They are used to treat severe, throbbing headaches, such as migraine and cluster headaches. Dihydroergotamine and ergotamine are not ordinary pain relievers. They will not relieve any kind of pain other than throbbing headaches. Because these medicines can cause serious side effects, they are usually used for patients whose headaches are not relieved by acetaminophen, aspirin, or other pain relievers.

Dihydroergotamine and ergotamine may cause blood vessels in the body to constrict (become narrower). This effect can lead to serious side effects that are caused by a decrease in the flow of blood (blood circulation) to many parts of the body.

The caffeine present in many ergotamine-containing combinations helps ergotamine work better and faster by causing more of it to be quickly absorbed into the body. The belladonna alkaloids, dimenhydrinate, and diphenhydramine in some combinations help to relieve nausea and vomiting, which often occur together with the headaches. Dimenhydrinate, diphenhydramine, and pentobarbital also help the patient relax and even sleep. This also helps relieve headaches.

Dihydroergotamine is also used for other conditions, as determined by your doctor.

These medicines are available only with your doctor's prescription.

This product is available in the following dosage forms:

Suppository
Tablet

Before Using

Allergies

Tell your doctor if you have ever had any unusual or allergic reaction to medicines in this group or any other medicines. Also tell your health care professional if you have any other types of allergies, such as to foods dyes, preservatives, or animals. For non-prescription products, read the label or package ingredients carefully.

Pediatric

For dihydroergotamine and ergotamine: These medicines are used to relieve severe, throbbing headaches in children 6 years of age or older. They have not been shown to cause different side effects or problems in children than they do in adults. However, these medicines can cause serious side effects in any patient. Therefore, it is especially important that you discuss with the child's doctor the good that this medicine may do as well as the risks of using it.

For belladonna alkaloids: Young children, especially children with spastic paralysis or brain damage, may be especially sensitive to the effects of belladonna alkaloids. This may increase the chance of side effects during treatment.

For dimenhydrinate, diphenhydramine, and pentobarbital: Although these medicines often cause drowsiness, some children become excited after taking them.

For dihydroergotamine and ergotamine: The chance of serious side effects caused by decreases in blood flow is increased in elderly people receiving these medicines.

For belladonna alkaloids, dimenhydrinate, diphenhydramine, and pentobarbital: Elderly people are more sensitive than younger adults to the effects of these medicines. This may increase the chance of side effects such as excitement, depression, dizziness, drowsiness, and confusion.

Geriatric

Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. Many medicines can add to or decrease the effects of the belladonna alkaloids, caffeine, dimenhydrinate, diphenhydramine, or pentobarbital present in some of these headache medicines. Therefore, you should tell your health care professional if you are taking any other prescription or nonprescription (over-the-counter [OTC]) medicine. This is especially important if any medicine you take causes excitement, trouble in sleeping, dryness of the mouth, dizziness, or drowsiness.

Pregnancy

Use of dihydroergotamine or ergotamine by pregnant women may cause serious harm, including death of the fetus and miscarriage. Therefore, these medicines should not be used during pregnancy.

Breastfeeding

For dihydroergotamine and ergotamine: These medicines pass into the breast milk and may cause unwanted effects, such as vomiting, diarrhea, weak pulse, changes in blood pressure, or convulsions (seizures) in nursing babies. Large amounts of these medicines may also decrease the flow of breast milk.

For caffeine: Caffeine passes into the breast milk. Large amounts of it may cause the baby to appear jittery or to have trouble in sleeping.

For belladonna alkaloids, dimenhydrinate, and diphenhydramine: These medicines have drying effects. Therefore, it is possible that they may reduce the amount of breast milk in some people. Dimenhydrinate passes into the breast milk.

For pentobarbital: Pentobarbital passes into the breast milk. Large amounts of it may cause unwanted effects such as drowsiness in nursing babies.

Be sure that you discuss these possible problems with your doctor before taking any of these medicines.

Drug Interactions

Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. When you are taking any of these medicines, it is especially important that your healthcare professional know if you are taking any of the medicines listed below. The following interactions have been selected on the basis of their potential significance and are not necessarily all-inclusive.

Using medicines in this class with any of the following medicines is not recommended. Your doctor may decide not to treat you with a medication in this class or change some of the other medicines you take.

Atazanavir
Boceprevir
Cabotegravir
Cobicistat
Darunavir
Dasabuvir
Delamanid
Doravirine
Elvitegravir
Maraviroc
Mavacamten
Nirmatrelvir
Ombitasvir
Paritaprevir
Ranolazine
Rilpivirine
Riociguat
Ritonavir
Rivaroxaban
Telaprevir
Tenofovir Alafenamide
Viloxazine
Voriconazole

Using medicines in this class with any of the following medicines is usually not recommended, but may be required in some cases. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.

Abemaciclib
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Abrocitinib
Acalabrutinib
Acenocoumarol
Acepromazine
Alfentanil
Alfuzosin
Alprazolam
Amifampridine
Amiodarone
Amisulpride
Amlodipine
Amobarbital
Amprenavir
Anagrelide
Anileridine
Anisindione
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Apixaban
Apomorphine
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Benzhydrocodone
Bepridil
Bictegravir
Bosutinib
Brigatinib
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Budesonide
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Butabarbital
Butalbital
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Cannabis
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Other Interactions

Certain medicines should not be used at or around the time of eating food or eating certain types of food since interactions may occur. Using alcohol or tobacco with certain medicines may also cause interactions to occur. Discuss with your healthcare professional the use of your medicine with food, alcohol, or tobacco.

Using medicines in this class with any of the following is usually not recommended, but may be unavoidable in some cases. If used together, your doctor may change the dose or how often you use your medicine, or give you special instructions about the use of food, alcohol, or tobacco.

Tobacco

Proper Use

Use this medicine only as directed by your doctor. Do not use more of it, and do not use it more often, than directed. If the amount you are to use does not relieve your headache, check with your doctor. Taking too much dihydroergotamine or ergotamine, or taking it too often, may cause serious effects, especially in elderly patients. Also, if a headache medicine (especially ergotamine) is used too often for migraines, it may lose its effectiveness or even cause a type of physical dependence. If this occurs, your headaches may actually get worse

This medicine works best if you:

Use it at the first sign of headache or migraine attack. If you get warning signals of a coming migraine, take it before the headache actually starts
Lie down in a quiet, dark room until you are feeling better

Your doctor may direct you to take another medicine to help prevent headaches. It is important that you follow your doctor's directions, even if your headaches continue to occur. Headache-preventing medicines may take several weeks to start working. Even after they do start working, your headaches may not go away completely. However, your headaches should occur less often, and they should be less severe and easier to relieve. This can reduce the amount of dihydroergotamine, ergotamine, or pain relievers that you need. If you do not notice any improvement after several weeks of headache-preventing treatment, check with your doctor.

For patients using dihydroergotamine:

Dihydroergotamine is given only by injection. Your health care professional will teach you how to inject yourself with the medicine. Be sure to follow the directions carefully. Check with your health care professional if you have any problems using the medicine.

For patients using the sublingual (under-the-tongue) tablets of ergotamine:

To use—Place the tablet under your tongue and let it remain there until it disappears. The sublingual tablet should not be chewed or swallowed, because it works faster when it is absorbed into the body through the lining of the mouth. Do not eat, drink, or smoke while the tablet is under your tongue.

For patients using rectal suppository forms of a headache medicine:

If the suppository is too soft to use, chill it in the refrigerator for 30 minutes or run cold water over it before removing the foil wrapper.
If you have been directed to use part of a suppository, you should divide the suppository into pieces that all contain the same amount of medicine. To do this, use a sharp knife and carefully cut the suppository lengthwise (from top to bottom) into pieces that are the same size. The suppository will be easier to cut if it has been kept in the refrigerator.
To insert the suppository—First remove the foil wrapper and moisten the suppository with cold water. Lie down on your side and use your finger to push the suppository well up into the rectum

Dosing

The dose medicines in this class will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average doses of these medicines. If your dose is different, do not change it unless your doctor tells you to do so.

The amount of medicine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine.

For dihydroergotamine

For relieving a migraine or cluster headache:
- Adults—1 mg. If your headache is not better, and no side effects are occurring, a second 1-mg dose may be used at least one hour later.
For relieving a migraine headache:
- Children 6 years of age and older—It is not likely that a child will be receiving dihydroergotamine at home. If a child needs the medicine, the dose will have to be determined by the doctor.

For ergotamine

For oral (capsules or tablets) and sublingual (under-the-tongue tablets) dosage forms:
- For relieving a migraine or cluster headache:
  - Adults—1 or 2 mg of ergotamine. If your headache is not better, and no side effects are occurring, a second dose and even a third dose may be taken; however the doses should be taken at least 30 minutes apart. People who usually need more than one dose of the medicine, and who do not get side effects from it, may be able to take a larger first dose of not more than 3 mg of ergotamine. This may provide better relief of the headache with only one dose. The medicine should not be taken more often than 2 times a week, at least five days apart.
- For preventing cluster headaches
  - Adults—The dose of ergotamine, and the number of doses you need every day, will depend on how many headaches you usually get each day. For some people, 1 or 2 mg of ergotamine once a day may be enough. Other people may need to take 1 or 2 mg of ergotamine 2 or 3 times a day.
- For relieving migraine headaches:
  - Children 6 years of age and older—1 mg of ergotamine. If the headache is not better, and no side effects are occurring, a second dose and even a third dose may be taken; however, the doses should be taken at least 30 minutes apart. Children should not take more than 3 mg of ergotamine a day in the form of capsules or tablets. Also, this medicine should not be taken more often than 2 times a week, at least five days apart.
For rectal suppository dosage form:
- For relieving migraine or cluster headaches:
  - Adults—Usually 1 mg of ergotamine, but the dose may range from half of this amount to up to 2 mg. If your headache is not better, and no side effects are occurring, a second dose and even a third dose may be used; however the doses should be taken at least 30 minutes apart. People who usually need more than one dose of the medicine, and who do not get side effects from it, may be able to use a larger first dose of not more than 3 mg. This may provide better relief of the headache with only one dose. Adults should not use more than 4 mg of ergotamine a day in suppository form. Also, this medicine should not be used more often than 2 times a week, at least five days apart.
- For relieving migraine headaches:
  - Children 6 years of age and older—One-half or 1 mg of ergotamine. Children should not receive more than 1 mg a day of ergotamine in suppository form. Also, this medicine should not be used more often than 2 times a week, at least five days apart.

Storage

Keep out of the reach of children.

Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Keep from freezing.

Do not keep outdated medicine or medicine no longer needed.

Suppositories should be stored in a cool place, but not allowed to freeze. Some manufacturers recommend keeping them in a refrigerator; others do not. Follow the directions on the package. However, cutting the suppository into smaller pieces, if you need to do so, will be easier if the suppository is kept in the refrigerator.

Precautions

Check with your doctor:

If your migraine headaches are worse than they were before you started using this medicine, or your headache medicine stops working as well as it did when you first started using it. This may mean that you are in danger of becoming dependent on the headache medicine. Do not try to get better relief by increasing the dose.
If your migraine headaches are occurring more often than they did before you started using this medicine. This is especially important if a new headache occurs within 1 day after you took your last dose of headache medicine, or if you are having headaches every day. This may mean that you are dependent on the headache medicine. Continuing to take this medicine will cause even more headaches later on. Your doctor can give you advice on how to relieve the headaches.

Drinking alcoholic beverages can make headaches worse or cause new headaches to occur. People who suffer from severe headaches should probably avoid alcoholic beverages, especially during a headache.

Smoking or nicotine replacement therapy products may increase some of the harmful effects of dihydroergotamine or ergotamine. It is best to avoid smoking or the use of nicotine replacement therapy products for several hours after taking these medicines.

Dihydroergotamine and ergotamine may make you more sensitive to cold temperatures, especially if you have blood circulation problems. They tend to decrease blood flow in the skin, fingers, and toes. Dress warmly during cold weather and be careful during prolonged exposure to cold temperatures. This is especially important for older patients, who are more likely than younger adults to already have problems with their circulation.

If you have a serious infection or illness of any kind, check with your doctor before using this medicine, since you may be more sensitive to its effects.

For patients taking one of the combination medicines that contains caffeine:

Caffeine may interfere with the results of a test that uses dipyridamole (e.g., Persantine) to help find out how well your blood is flowing through certain blood vessels. You should not have any caffeine for at least 12 hours before the test.

Caffeine may also interfere with some other laboratory tests. Before having any other laboratory tests, tell the person in charge if you have taken a medicine that contains caffeine.

For patients taking one of the combination medicines that contains belladonna alkaloids, dimenhydrinate, diphenhydramine, or pentobarbital:

These medicines may cause some people to have blurred vision or to become drowsy, dizzy, lightheaded, or less alert than they are normally. These effects may be especially severe if you also take CNS depressants (medicines that slow down the nervous system, possibly causing drowsiness) together with one of these combination medicines. Some examples of CNS depressants are antihistamines or medicine for hay fever, other allergies, or colds; sedatives, tranquilizers, or sleeping medicine; prescription pain medicine or narcotics; barbiturates; medicine for seizures; muscle relaxants; and antiemetics (medicines that prevent or relieve nausea or vomiting). If you are not able to lie down for a while, make sure you know how you react to this medicine or combination of medicines before you drive, use machines, or do anything else that could be dangerous if you are dizzy or are not alert and able to see well.
Belladonna alkaloids, dimenhydrinate, and diphenhydramine may cause dryness of the mouth, nose, and throat. For temporary relief of mouth dryness, use sugarless candy or gum, melt bits of ice in your mouth, or use a saliva substitute.
Belladonna alkaloids may interfere with certain laboratory tests that check the amount of acid in your stomach. They should not be taken for 24 hours before the test.
Dimenhydrinate and diphenhydramine may interfere with skin tests that show whether you are allergic to certain substances. They should not be taken for 3 days before the test.

Side Effects

Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.

Check with your doctor immediately if the following side effects occur, because they may mean that you are developing a problem with blood circulation:

Less common or rare

Anxiety or confusion (severe)
change in vision
chest pain
increase in blood pressure
muscle pain
pain in arms, legs, or lower back, especially if pain occurs in your calves or heels while you are walking
pale, bluish-colored, or cold hands or feet (not caused by cold temperatures and occurring together with other side effects listed in this section)
red or violet-colored blisters on the skin of the hands or feet

Less common or rare

Convulsions (seizures)
diarrhea
diarrhea, nausea, vomiting, or stomach pain or bloating (severe) occurring together with other signs of overdose or of problems with blood circulation
dizziness, drowsiness, or weakness (severe), occurring together with other signs of overdose or of problems with blood circulation
fast or slow heartbeat
headaches, more often and/or more severe than before
problems with moving bowels, occurring together with pain or discomfort in the rectum (with rectal suppositories only)
shortness of breath
unusual excitement

The following side effects may go away after a little while. Do not take any more medicine while they are present. If any of them occur together with other signs of problems with blood circulation, check with your doctor right away. Even if any of the following side effects occur without other signs of problems with blood circulation, check with your doctor if any of them continue for more than one hour:

More common

Coldness, numbness, or tingling in fingers, toes, or face
itching of skin
weakness in legs

Check with your doctor as soon as possible if any of the following side effects occur:

More common

Swelling of face, fingers, feet, or lower legs

Less common or rare

Absence of pulse
blurred vision
decrease in blood pressure
lightheadedness
fainting
fever
general feeling of illness
loss of appetite
lower abdominal pain
lower back pain
pounding in the ears
rapid, weak pulse
slow or irregular heartbeat
unusual tiredness

Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:

More common

Diarrhea, nausea, or vomiting (occurring without other signs of overdose or problems with blood circulation)
dizziness or drowsiness (occurring without other signs of overdose or problems with blood circulation, especially with combinations containing dimenhydrinate, diphenhydramine, or pentobarbital)
dryness of mouth (especially with combinations containing belladonna alkaloids, dimenhydrinate, or diphenhydramine)
nervousness or restlessness

Rare

Abdominal pain
difficulty in moving bowels
irregular bowel movements
rectal discomfort

After you stop taking this medicine, your body may need time to adjust. The length of time this takes depends on the amount of medicine you were taking and how long you took it. During this time check with your doctor if your headaches begin again or worsen.

Other side effects not listed may also occur in some patients. If you notice any other effects, check with your healthcare professional.

Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.

Portions of this document last updated: April 01, 2024

Original article: https://www.mayoclinic.org/drugs-supplements/headache-medicine-ergot-derivative-containing-oral-route-parenteral-route-rectal-route/precautions/DRG-20070161

Headache Medicine Ergot-Derivative-Containing (Oral Route, Parenteral Route, Rectal Route)

Description and Brand Names

Canadian Brand Name

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Before Using

Allergies

Pediatric

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Pregnancy

Breastfeeding

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Other Medical Problems

Proper Use

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For dihydroergotamine

For ergotamine

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Less common or rare

More common

More common

Less common or rare

More common

Rare

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