Dihydroergotamine (nasal)

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# Black Box Warning

# Overview
Dihydroergotamine (nasal) is an ergot that is FDA approved for the treatment of migraine headaches (with or without aura). There is a Black Box Warning for this drug as shown here.  Common adverse reactions include vasospasm, paraesthesia, hypertension, dizziness, anxiety, dyspnea, headache, flushing, diarrhea, rash, and pleural and retroperitoneal fibrosis.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray is indicated for the acute treatment of migraine headaches with or without aura.
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray is not intended for the prophylactic therapy of migraine or for the management of hemiplegic or basilar migraine.
- The solution used in Migranal (dihydroergotamine mesylate, USP) Nasal Spray (4 mg/mL) is intended for intranasal use and must not be injected.
- In clinical trials, Migranal (dihydroergotamine mesylate, USP) Nasal Spray has been effective for the acute treatment of migraine headaches with or without aura. One spray (0.5 mg) of Migranal (dihydroergotamine mesylate, USP) Nasal Spray should be administered in each nostril. Fifteen minutes later, an additional one spray (0.5 mg) of Migranal (dihydroergotamine mesylate, USP) Nasal Spray should be administered in each nostril, for a total dosage of four sprays (2.0 mg) of Migranal (dihydroergotamine mesylate, USP) Nasal Spray. Studies have shown no additional benefit from acute doses greater than 2.0 mg for a single migraine administration.
- The safety of doses greater than 3.0 mg in a 24 hour period and 4.0 mg in a 7 day period has not been established.
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray, should not be used for chronic daily administration.
- Prior to administration, the pump must be primed (i.e., squeeze 4 times) before use. Once the nasal spray applicator has been prepared, it should be discarded (with any remaining drug in opened vial ) after 8 hours.
- Prior to administration, the pump must be primed (i.e., squeeze 4 times) before use.
- Once the nasal spray applicator has been prepared, it should be discarded (with any remaining drug in opened vial after 8 hours).

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Dihydroergotamine (nasal) in adult patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Dihydroergotamine (nasal) in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding FDA-Labeled Use of Dihydroergotamine (nasal) in pediatric patients.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Dihydroergotamine (nasal) in pediatric patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Dihydroergotamine (nasal) in pediatric patients.

# Contraindications
- There have been a few reports of serious adverse events associated with the coadministration of dihydroergotamine and potent CYP 3A4 inhibitors, such as protease inhibitors and macrolide antibiotics, resulting in vasospasm that led to cerebral ischemia and/or ischemia of the extremities. The use of potent CYP 3A4 inhibitors (ritonavir, nelfinavir, indinavir, erythromycin, clarithromycin, troleandomycin, ketoconazole, itraconazole) with dihydroergotamine is, therefore contraindicated.
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray should not be given to patients with ischemic heart disease (angina pectoris, history of myocardial infarction, or documented silent ischemia) or to patients who have clinical symptoms or findings consistent with coronary artery vasospasm including Prinzmetal's variant angina. (See WARNINGS)
- Because Migranal (dihydroergotamine mesylate, USP) Nasal Spray may increase blood pressure, it should not be given to patients with uncontrolled hypertension.
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray, 5-HT1 agonists (e.g., sumatriptan), ergotamine-containing or ergot-type medications or methysergide should not be used within 24 hours of each other.
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray should not be administered to patients with hemiplegic or basilar migraine.
- In addition to those conditions mentioned above, Migranal (dihydroergotamine mesylate, USP) Nasal Spray is also contraindicated in patients with known peripheral arterial disease, sepsis, following vascular surgery, and severely impaired hepatic or renal function.
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray may cause fetal harm when administered to a pregnant woman. Dihydroergotamine possesses oxytocic properties and, therefore, should not be administered during pregnancy. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus.
- There are no adequate studies of dihydroergotamine in human pregnancy, but developmental toxicity has been demonstrated in experimental animals. In embryofetal development studies of dihydroergotamine mesylate nasal spray, intranasal administration to pregnant rats throughout the period of organogenesis resulted in decreased fetal body weights and/or skeletal ossification at doses of 0.16 mg/day (associated with maternal plasma dihydroergotamine exposures  approximately 0.4 -1.2 times the exposures in humans receiving the MRDD of 4 mg) or greater. A no effect level for embryo-fetal toxicity was not established in rats. Delayed skeletal ossification was also noted in rabbit fetuses following intranasal administration of 3.6 mg/day (maternal exposures approximately 7 times human exposures at the MRDD) during organogenesis. A no effect level was seen at 1.2 mg/day (maternal exposures approximately 2.5 times human exposures at the MRDD). When dihydroergotamine mesylate nasal spray was administered intranasally to female rats during pregnancy and lactation, decreased body weights and impaired reproductive function (decreased mating indices) were observed in the offspring at doses of 0.16 mg/day or greater. A no effect level was not established. Effects on development occurred at doses below those that produced evidence of significant maternal toxicity in these studies.
- Dihydroergotamine-induced intrauterine growth retardation has been attributed to reduced uteroplacental blood flow resulting from prolonged vasoconstriction of the uterine vessels and/or increased myometrial tone.
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray is contraindicated in patients who have previously shown hypersensitivity to ergot alkaloids.
- Dihydroergotamine mesylate should not be used by nursing mothers.
- Dihydroergotamine mesylate should not be used with peripheral and central vasoconstrictors because the combination may result in additive or synergistic elevation of blood pressure.

# Warnings
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray should only be used where a clear diagnosis of migraine headache has been established.
- CYP 3A4 Inhibitors (e.g. Macrolide Antibiotics and Protease Inhibitors)
- There have been rare reports of serious adverse events in connection with the coadministration of dihydroergotamine and potent CYP 3A4 inhibitors, such as protease inhibitors and macrolide antibiotics, resulting in vasospasm that led to cerebral ischemia and/or and ischemia of the extremities. The use of potent CYP 3A4 inhibitors with dihydroergotamine should therefore be avoided. Examples of some of the more potent CYP 3A4 inhibitors include: antifungals ketoconazole and itraconazole, the protease inhibitors ritonavir, nelfinavir, and indinavir, and macrolide antibiotics erythromycin, clarithromycin, and troleandomycin. Other less potent CYP 3A4 inhibitors should be administered with caution. Less potent inhibitors include saquinavir, nefazodone, fluconazole, grapefruit juice, fluoxetine, fluvoxamine, zileuton, and clotrimazole.
- These lists are not exhaustive, and the prescriber should consider the effects on CYP3A4 of other agents being considered for concomitant use with dihydroergotamine.
- There have been reports of pleural and retroperitoneal fibrosis in patients following prolonged daily use of injectable dihydroergotamine mesylate. Rarely, prolonged daily use of other ergot alkaloid drugs has been associated with cardiac valvular fibrosis. Rare cases have also been reported in association with the use of injectable dihydroergotamine mesylate; however, in those cases, patients also received drugs known to be associated with cardiac valvular fibrosis.
- Administration of Migranal (dihydroergotamine mesylate, USP) Nasal Spray, should not exceed the dosing guidelines and should not be used for chronic daily administration.
- Risk of Myocardial Ischemia and/or Infarction and Other Adverse Cardiac Events
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray should not be used by patients with documented ischemic or vasospastic coronary artery disease. It is strongly recommended that Migranal (dihydroergotamine mesylate, USP) Nasal Spray not be given to patients in whom unrecognized coronary artery disease (CAD) is predicted by the presence of risk factors (e.g., hypertension, hypercholesterolemia, smoker, obesity, diabetes, strong family history of CAD, females who are surgically or physiologically postmenopausal, or males who are over 40 years of age) unless a cardiovascular evaluation provides satisfactory clinical evidence that the patient is reasonably free of coronary artery and ischemic myocardial disease or other significant underlying cardiovascular disease. The sensitivity of cardiac diagnostic procedures to detect cardiovascular disease or predisposition to coronary artery vasospasm is modest, at best. If, during the cardiovascular evaluation, the patient's medical history or electrocardiographic investigations reveal findings indicative of or consistent with coronary artery vasospasm or myocardial ischemia, Migranal (dihydroergotamine mesylate, USP) Nasal Spray should not be administered.
- For patients with risk factors predictive of CAD who are determined to have a satisfactory cardiovascular evaluation, it is strongly recommended that administration of the first dose of Migranal (dihydroergotamine mesylate, USP) Nasal Spray take place in the setting of a physician's office or similar medically staffed and equipped facility unless the patient has previously received dihydroergotamine mesylate. Because cardiac ischemia can occur in the absence of clinical symptoms, consideration should be given to obtaining on the first occasion of use an electrocardiogram (ECG) during the interval immediately following Migranal (dihydroergotamine mesylate, USP) Nasal Spray, in these patients with risk factors.
- It is recommended that patients who are intermittent long-term users of Migranal (dihydroergotamine mesylate, USP) Nasal Spray and who have or acquire risk factors predictive of CAD, as described above, undergo periodic interval cardiovascular evaluation as they continue to use Migranal (dihydroergotamine mesylate, USP) Nasal Spray.
- The systematic approach described above is currently recommended as a method to identify patients in whom Migranal (dihydroergotamine mesylate, USP) Nasal Spray may be used to treat migraine headaches with an acceptable margin of cardiovascular safety.
- No deaths have been reported in patients using Migranal (dihydroergotamine mesylate, USP) Nasal Spray. However, the potential for adverse cardiac events exists.
- Serious adverse cardiac events, including acute myocardial infarction, life-threatening disturbances of cardiac rhythm, and death have been reported to have occurred following the administration of dihydroergotamine mesylate injection (e.g., D.H.E. 45 Injection). Considering the extent of use of dihydroergotamine mesylate in patients with migraine, the incidence of these events is extremely low.
- Cerebral hemorrhage, subarachnoid hemorrhage, stroke, and other cerebrovascular events have been reported in patients treated with D.H.E. 45 Injection; and some have resulted in fatalities. In a number of cases, it appears possible that the cerebrovascular events were primary, the D.H.E. 45 Injection having been administered in the incorrect belief that the symptoms experienced were a consequence of migraine, when they were not. It should be noted that patients with migraine may be at increased risk of certain cerebrovascular events (e.g., stroke, hemorrhage, transient ischemic attack).
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray, like other ergot alkaloids, may cause vasospastic reactions other than coronary artery vasospasm.
- Myocardial and peripheral vascular ischemia have been reported with Migranal (dihydroergotamine mesylate, USP) Nasal Spray.
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray associated vasospastic phenomena may also cause muscle pains, numbness, coldness, pallor, and cyanosis of the digits. In patients with compromised circulation, persistent vasospasm may result in gangrene or death, Migranal (dihydroergotamine mesylate, USP) Nasal Spray should be discontinued immediately if signs or symptoms of vasoconstriction develop.
- Significant elevation in blood pressure has been reported on rare occasions in patients with and without a history of hypertension treated with Migranal (dihydroergotamine mesylate, USP) Nasal Spray and dihydroergotamine mesylate injection. Migranal (dihydroergotamine mesylate, USP) Nasal Spray is contraindicated in patients with uncontrolled hypertension.
- An 18% increase in mean pulmonary artery pressure was seen following dosing with another 5HT1 agonist in a study evaluating subjects undergoing cardiac catheterization.
- Approximately 30% of patients using Migranal (dihydroergotamine mesylate, USP) Nasal Spray (compared to 9% of placebo patients) have reported irritation in the nose, throat, and/or disturbances in taste. Irritative symptoms include congestion, burning sensation, dryness, paraesthesia, discharge, epistaxis, pain, or soreness.
- The symptoms were predominantly mild to moderate in severity and transient. In approximately 70% of the above mentioned cases, the symptoms resolved within four hours after dosing with Migranal (dihydroergotamine mesylate, USP) Nasal Spray.
- Examinations of the nose and throat in a small subset (N = 66) of study participants treated for up to 36 months (range 1-36 months) did not reveal any clinically noticeable injury. Other than this limited number of patients, the consequences of extended and repeated use of Migranal (dihydroergotamine mesylate, USP) Nasal Spray on the nasal and/or respiratory mucosa have not been systematically evaluated in patients.
- Nasal tissue in animals treated with dihydroergotamine mesylate daily at nasal cavity surface area exposures (in mg/mm2) that were equal to or less than those achieved in humans receiving the maximum recommended daily dose of 0.08 mg/kg/day showed mild mucosal irritation characterized by mucous cell and transitional cell hyperplasia and squamous cell metaplasia. Changes in rat nasal mucosa at 64 weeks were less severe than at 13 weeks. Local effects on respiratory tissue after chronic intranasal dosing in animals have not been evaluated.

# Adverse Reactions

## Clinical Trials Experience
- During clinical studies and the foreign postmarketing experience with Migranal (dihydroergotamine mesylate, USP) Nasal Spray there have been no fatalities due to cardiac events.
- Serious cardiac events, including some that have been fatal, have occurred following use of the parenteral form of dihydroergotamine mesylate (D.H.E. 45 Injection), but are extremely rare. Events reported have included coronary artery vasospasm, transient myocardial ischemia, myocardial infarction, ventricular tachycardia, and ventricular fibrillation.
- Fibrotic complications have been reported in association with long term use of injectable dihydroergotamine mesylate.
- Of the 1,796 patients and subjects treated with Migranal (dihydroergotamine mesylate, USP) Nasal Spray doses 2 mg or less in U.S. and foreign clinical studies, 26 (1.4%) discontinued because of adverse events. The adverse events associated with discontinuation were, in decreasing order of frequency: rhinitis 13,dizziness 2, facial edema 2, and one each due to cold sweats, accidental trauma, depression, elective surgery, somnolence, allergy, vomiting, hypotension, and paraesthesia.
- The most commonly reported adverse events associated with the use of Migranal (dihydroergotamine mesylate, USP) Nasal Spray during placebo-controlled, double-blind studies for the treatment of migraine headache and not reported at an equal incidence by placebo-treated patients were rhinitis, altered sense of taste, application site reactions, dizziness, nausea, and vomiting. The events cited reflect experience gained under closely monitored conditions of clinical trials in a highly selected patient population. In actual clinical practice or in other clinical trials, these frequency estimates may not apply, as the conditions of use, reporting behavior, and the kinds of patients treated may differ.
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray was generally well tolerated. In most instances these events were transient and self-limited and did not result in patient discontinuation from a study. The following table summarizes the incidence rates of adverse events reported by at least 1% of patients who received Migranal (dihydroergotamine mesylate, USP) Nasal Spray for the treatment of migraine headaches during placebo-controlled, double-blind clinical studies and were more frequent than in those patients receiving placebo.
- In the paragraphs that follow, the frequencies of less commonly reported adverse clinical events are presented. Because the reports include events observed in open and uncontrolled studies, the role of Migranal (dihydroergotamine mesylate, USP) Nasal Spray in their causation cannot be reliably determined. Furthermore, variability associated with adverse event reporting, the terminology used to describe adverse events, etc., limit the value of the quantitative frequency estimates provided. Event frequencies are calculated as the number of patients who used Migranal (dihydroergotamine mesylate, USP) Nasal Spray in placebo-controlled trials and reported an event divided by the total number of patients (n=1796) exposed to Migranal (dihydroergotamine mesylate, USP) Nasal Spray. All reported events are included except those already listed in the previous table, those too general to be informative, and those not reasonably associated with the use of the drug. Events are further classified within body system categories and enumerated in order of decreasing frequency using the following definitions: frequent adverse events are defined as those occurring in at least 1/100 patients; infrequent adverse events are those occurring in 1/100 to 1/1,000 patients; and rare adverse events are those occurring in fewer than 1/1,000 patients.
- Skin and Appendages: Infrequent: petechia, pruritus, rash, cold clammy skin; Rare: papular rash, urticaria, herpes simplex.
- Musculoskeletal: Infrequent: cramps, myalgia, muscular weakness, dystonia; Rare: arthralgia, involuntary muscle contractions, rigidity.
- Central and Peripheral Nervous System: Infrequent: confusion, tremor, hypoesthesia, vertigo; Rare: speech disorder, hyperkinesia, stupor, abnormal gait, aggravated migraine.
- Autonomic Nervous System: Infrequent: increased sweating.
- Special Senses: Infrequent: sense of smell altered, photophobia, conjunctivitis, abnormal lacrimation, abnormal vision, tinnitus, earache; Rare: eye pain.
- Psychiatric: Infrequent: nervousness, euphoria, insomnia, concentration impaired; Rare: anxiety, anorexia, depression.
- Gastrointestinal: Infrequent:abdominal pain, dyspepsia, dysphagia, hiccup; Rare: increased salivation, esophagospasm.
- Cardiovascular: Infrequent: edema, palpitation, tachycardia; Rare: hypotension, peripheral ischemia, angina.
- Respiratory System: Infrequent: dyspnea, upper respiratory tract infections; Rare: bronchospasm, bronchitis, pleural pain, epistaxis.
- Urinary System: Infrequent: increased frequency of micturition, cystitis.
- Reproductive, Female: Rare: pelvic inflammation, vaginitis.
- Body as a Whole - General: Infrequent: feeling cold, malaise, rigors, fever, periorbital edema; Rare: flu-like symptoms, shock, loss of voice, yawning.
- Application Site: Infrequent: local anesthesia.

## Postmarketing Experience
- Voluntary reports of adverse events temporally associated with dihydroergotamine products used in the management of migraine that have been received since the introduction of the injectable formulation are included in this section save for those already listed above. Because of their source (open and uncontrolled clinical use), whether or not events reported in association with the use of dihydroergotamine are causally related to it cannot be determined. There have been reports of pleural and retroperitoneal fibrosis in patients following prolonged daily use of injectable dihydroergotamine mesylate. Migranal (dihydroergotamine mesylate, USP) Nasal Spray is not recommended for prolonged daily use.

# Drug Interactions
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray should not be used with peripheral vasoconstrictors because the combination may cause synergistic elevation of blood pressure.
- Sumatriptan has been reported to cause coronary artery vasospasm, and its effect could be additive with Migranal (dihydroergotamine mesylate, USP) Nasal Spray. Sumatriptan and Migranal (dihydroergotamine mesylate, USP) Nasal Spray should not be taken within 24 hours of each other. (See CONTRAINDICATIONS)
- Although the results of a clinical study did not indicate a safety problem associated with the administration of Migranal (dihydroergotamine mesylate, USP) Nasal Spray to subjects already receiving propranolol, there have been reports that propranolol may potentiate the vasoconstrictive action of ergotamine by blocking the vasodilating property of epinephrine.
- Nicotine may provoke vasoconstriction in some patients, predisposing to a greater ischemic response to ergot therapy.
- CYP 3A4 Inhibitors (e.g.Macrolide Antibiotics and Protease Inhibitors)
- Weakness, hyperreflexia, and incoordination have been reported rarely when 5HT1 agonists have been coadministered with SSRI's (e.g., fluoxetine, fluvoxamine, paroxetine, sertraline). There have been no reported cases from spontaneous reports of drug interaction between SSRI's and Migranal (dihydroergotamine mesylate, USP) Nasal Spray or D.H.E. 45.
- The effect of oral contraceptives on the pharmacokinetics of Migranal (dihydroergotamine mesylate, USP) Nasal Spray has not been studied.
- Carcinogenesis
- Assessment of the carcinogenic potential of dihydroergotamine mesylate in mice and rats is ongoing.
- Mutagenesis
- Dihydroergotamine mesylate was clastogenic in two in vitro chromosomal aberration assays, the V79 Chinese hamster cell assay with metabolic activation and the cultured human peripheral blood lymphocyte assay. There was no evidence of mutagenic potential when dihydroergotamine mesylate was tested in the presence or absence of metabolic activation in two gene mutation assays (the Ames test and the in vitro mammalian Chinese hamster V79/HGPRT assay) and in an assay for DNA damage (the rat hepatocyte unscheduled DNA synthesis test). Dihydroergotamine was not clastogenic in the in vivo mouse and hamster micronucleus tests.
- There was no evidence of impairment of fertility in rats given intranasal doses of Migranal (dihydroergotamine mesylate, USP) Nasal Spray up to 1.6 mg/day (associated with mean plasma dihydroergotamine mesylate exposures  approximately 9 to 11 times those in humans receiving the MRDD of 4 mg).

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): X
- Pregnancy Category
Pregnancy Category (AUS):
- Australian Drug Evaluation Committee (ADEC) Pregnancy Category
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Dihydroergotamine (nasal) in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Dihydroergotamine (nasal) during labor and delivery.

### Nursing Mothers
- Ergot drugs are known to inhibit prolactin. It is likely that Migranal (dihydroergotamine mesylate, USP) Nasal Spray is excreted in human milk, but there are no data on the concentration of dihydroergotamine in human milk. It is known that ergotamine is excreted in breast milk and may cause vomiting, diarrhea, weak pulse, and unstable blood pressure in nursing infants. Because of the potential for these serious adverse events in nursing infants exposed to Migranal (dihydroergotamine mesylate, USP) Nasal Spray, nursing should not be undertaken with the use of Migranal (dihydroergotamine mesylate, USP) Nasal Spray.

### Pediatric Use
There is no FDA guidance on the use of Dihydroergotamine (nasal) with respect to pediatric patients.

### Geriatic Use
There is no information about the safety and effectiveness of Migranal (dihydroergotamine mesylate, USP) Nasal Spray in this population because patients over age 65 were excluded from the controlled clinical trials.

### Gender
There is no FDA guidance on the use of Dihydroergotamine (nasal) with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Dihydroergotamine (nasal) with respect to specific racial populations.

### Renal Impairment
There is no FDA guidance on the use of Dihydroergotamine (nasal) in patients with renal impairment.

### Hepatic Impairment
There is no FDA guidance on the use of Dihydroergotamine (nasal) in patients with hepatic impairment.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Dihydroergotamine (nasal) in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Dihydroergotamine (nasal) in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Intranasal

### Monitoring
There is limited information regarding Monitoring of Dihydroergotamine (nasal) in the drug label.

# IV Compatibility
There is limited information regarding IV Compatibility of Dihydroergotamine (nasal) in the drug label.

# Overdosage
- To date, there have been no reports of acute overdosage with this drug. Due to the risk of vascular spasm, exceeding the recommended dosages of Migranal (dihydroergotamine mesylate, USP) Nasal Spray is to be avoided.
- Excessive doses of dihydroergotamine may result in peripheral signs and symptoms of ergotism. Treatment includes discontinuance of the drug, local application of warmth to the affected area, the administration of vasodilators, and nursing care to prevent tissue damage.
- In general, the symptoms of an acute Migranal (dihydroergotamine mesylate, USP) Nasal Spray overdose are similar to those of an ergotamine overdose, although there is less pronounced nausea and vomiting with Migranal (dihydroergotamine mesylate, USP) Nasal Spray. The symptoms of an ergotamine overdose include the following: numbness, tingling, pain, and cyanosis of the extremities associated with diminished or absent peripheral pulses; respiratory depression; an increase and/or decrease in blood pressure, usually in that order; confusion, delirium, convulsions, and coma; and/or some degree of nausea, vomiting, and abdominal pain.
- In laboratory animals, significant lethality occurs when dihydroergotamine is given at I.V. doses of 44 mg/kg in mice, 130 mg/kg in rats, and 37 mg/kg in rabbits.
- Up-to-date information about the treatment of overdosage can often be obtained from a certified Regional Poison Control Center.

# Pharmacology

## Mechanism of Action
- Dihydroergotamine binds with high affinity to 5-HT1D and 5-HT1D receptors. It also binds with high affinity to serotonin 5-HT1A, 5-HT2A, and 5-HT2C receptors, noradrenaline 2A, 2B and , receptors, and dopamine D2L and D3 receptors.
- The therapeutic activity of dihydroergotamine in migraine is generally attributed to the agonist effect at 5-HT1D receptors. Two current theories have been proposed to explain the efficacy of 5-HT1D receptor agonists in migraine. One theory suggests that activation of 5-HT1D receptors located on intracranial blood vessels, including those on arterio-venous anastomoses, leads to vasoconstriction, which correlates with the relief of migraine headache. The alternative hypothesis suggests that activation of 5-HT1D receptors on sensory nerve endings of the trigeminal system results in the inhibition of pro-inflammatory neuropeptide release.
- In addition, dihydroergotamine possesses oxytocic properties.

## Structure
- D.H.E. 45 is ergotamine hydrogenated in the 9, 10 position as the mesylate salt. D.H.E. 45 is known chemically as ergotaman-3 ,6 ,18-trione,9,10-dihydro-12 -hydroxy-2 -methyl-5 -(phenylmethyl)-,(5 )-, monomethanesulfonate. Its molecular weight is 679.80 and its empirical formula is C33H37N5O5CH4O3S.
The chemical structure is

## Pharmacodynamics
There is limited information regarding Pharmacodynamics of Dihydroergotamine (nasal) in the drug label.

## Pharmacokinetics
- Dihydroergotamine mesylate is poorly bioavailable following oral administration. Following intranasal administration, however, the mean bioavailability of dihydroergotamine mesylate is 32% relative to the injectable administration. Absorption is variable, probably reflecting both intersubject differences of absorption and the technique used for self-administration.
- Dihydroergotamine mesylate is 93% plasma protein bound. The apparent steady-state volume of distribution is approximately 800 liters.
- Four dihydroergotamine mesylate metabolites have been identified in human plasma following oral administration. The major metabolite, 8'--hydroxydihydroergotamine, exhibits affinity equivalent to its parent for adrenergic and 5-HT receptors and demonstrates equivalent potency in several venoconstrictor activity models, in vivo and in vitro. The other metabolites, i.e., dihydrolysergic acid, dihydrolysergic amide and a metabolite formed by oxidative opening of the proline ring are of minor importance. Following nasal administration, total metabolites represent only 20%-30% of plasma AUC. The systemic clearance of dihydroergotamine mesylate following I.V. and I.M. administration is 1.5 L/min. Quantitative pharmacokinetic characterization of the four metabolites has not been performed.
- The major excretory route of dihydroergotamine is via the bile in the feces. After intranasal administration the urinary recovery of parent drug amounts to about 2% of the administered dose compared to 6% after I.M. administration. The total body clearance is 1.5 L/min which reflects mainly hepatic clearance. The renal clearance (0.1 L/min) is unaffected by the route of dihydroergotamine administration. The decline of plasma dihydroergotamine is biphasic with a terminal half-life of about 10 hours.
- No studies have been conducted on the effect of renal or hepatic impairment, gender, race, or ethnicity on dihydroergotamine pharmacokinetics. Migranal (dihydroergotamine mesylate, USP) Nasal Spray is contraindicated in patients with severely impaired hepatic or renal function.
- The pharmacokinetics of dihydroergotamine did not appear to be significantly affected by the concomitant use of a local vasoconstrictor (e.g., fenoxazoline).
- Multiple oral doses of the -adrenoceptor antagonist propranolol, used for migraine prophylaxis, had no significant influence on the Cmax, Tmax or AUC of dihydroergotamine doses up to 4 mg. Pharmacokinetic interactions have been reported in patients treated orally with other ergot alkaloids (e.g., increased levels of ergotamine) and macrolide antibiotics, principally troleandomycin, presumably due to inhibition of cytochrome P450 3A metabolism of the alkaloids by troleandomycin. Dihydroergotamine has also been shown to be an inhibitor of cytochrome P450 3A catalyzed reactions and rare reports of ergotism have been obtained from patients treated with dihydroergotamine and macrolide antibiotics (e.g., troleandomycin, clarithromycin, erythromycin), and in patients treated with dihydroergotamine and protease inhibitors (e.g. ritonavir), presumably due to inhibition of cytochrome P450 3A metabolism of ergotamine (See CONTRAINDICATIONS). No pharmacokinetic interactions involving other cytochrome P450 isoenzymes are known.

## Nonclinical Toxicology
There is limited information regarding Nonclinical Toxicology of Dihydroergotamine (nasal) in the drug label.

# Clinical Studies
- The efficacy of Migranal (dihydroergotamine mesylate, USP) Nasal Spray for the acute treatment of migraine headaches was evaluated in four randomized, double blind, placebo controlled studies in the U.S. The patient population for the trials was predominantly female (87%) and Caucasian (95%) with a mean age of 39 years (range 18 to 65 years). Patients treated a single moderate to severe migraine headache with a single dose of study medication and assessed pain severity over the 24 hours following treatment. Headache response was determined 0.5, 1, 2, 3 and 4 hours after dosing and was defined as a reduction in headache severity to mild or no pain. In studies 1 and 2, a four-point pain intensity scale was utilized; in studies 3 and 4, a five-point scale was used that included both pain response and restoration of function for "severe" or "incapacitating" pain, a less clear endpoint. Although rescue medication was allowed in all four studies, patients were instructed not to use them during the four hour observation period. In studies 3 and 4, a total dose of 2 mg was compared to placebo. In studies 1 and 2, doses of 2 and 3 mg were evaluated, and showed no advantage of the higher dose for a single treatment. In all studies, patients received a regimen consisting of 0.5 mg in each nostril, repeated in 15 minutes (and again in another 15 minutes for the 3 mg dose in studies 1 and 2).

# How Supplied
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray is available (as a clear, colorless to faintly yellow solution) in 3.5 mL amber glass vials containing 4 mg of dihydroergotamine mesylate, USP.
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray is provided as a package of 8 units, administration instruction sheet, and one package insert. Each unit consists of one vial and one sprayer. (NDC 0187-0245-03)

## Storage
- Store below 25C (77F). Do not refrigerate or freeze.

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray.
- The solution used in Migranal (dihydroergotamine mesylate, USP) Nasal Spray (4 mg/mL) is intended for intranasal use and must not be injected.
- Please read this information carefully before using your Migranal (dihydroergotamine mesylate, USP) Nasal Spray for the first time. Keep this information handy for future reference. This leaflet does not contain all of the information on Migranal (dihydroergotamine mesylate, USP) Nasal Spray. Your pharmacist and/or health care provider can provide more detailed information.
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray has been evaluated in a limited number of patients long term (e.g., 1 year or longer).
- Migranal (dihydroergotamine mesylate, USP) Nasal Spray is intended to treat an active migraine headache. Do not try to use it to prevent a headache if you have no symptoms. Do not use it to treat common tension headache or a headache that is not at all typical of your usual migraine headache. Administration of Migranal (dihydroergotamine mesylate, USP) Nasal Spray, should not exceed the dosing guidelines and should not be used for chronic daily administration. There have been reports of fibrosis (stiffening) in the lung or kidney areas in patients following prolonged daily use of injectable dihydroergotamine mesylate. Rarely, prolonged daily use of other ergot alkaloid drugs (the class of drugs to which Migranal (dihydroergotamine mesylate, USP) Nasal Spray belongs) has been associated with heart valvular fibrosis. Rare cases have also been reported in association with the use of injectable dihydroergotamine mesylate; however, in those cases, patients also received drugs known to be associated with heart valvular fibrosis.
- Do not use Migranal (dihydroergotamine mesylate, USP) Nasal Spray if you:
- Are pregnant or nursing.
- Have any disease affecting your heart, arteries, or circulation.
are taking certain anti-HIV medications (protease inhibitors)
are taking a macrolide antibiotic such as troleandomycin, clarithromycin or erythromycin.
- Important questions to consider before using Migranal (dihydroergotamine mesylate, USP) Nasal Spray
- Please answer the following questions before you use your Migranal (dihydroergotamine mesylate, USP) Nasal Spray. If you answer YES to any of these questions or are unsure of the answer, you should talk to your doctor before using Migranal (dihydroergotamine mesylate, USP) Nasal Spray.
- Do you have high blood pressure?
- Do you have chest pain, shortness of breath, heart disease, or have you had any surgery on your heart arteries?
- Do you have risk factors for heart disease (such as high blood pressure, high cholesterol, obesity, diabetes, smoking, strong family history of heart disease, or are you postmenopausal or a male over 40)?
- Do you have any problems with blood circulation in your arms or legs, fingers, or toes?
- Are you pregnant? Do you think you might be pregnant? Are you trying to become pregnant? Are you sexually active and not using birth control? Are you breast feeding?
- Have you ever had to stop taking this or any other medication because of an allergy or bad reaction?
- Are you taking any other migraine medications, erythromycin or other antibiotics, or medications for blood pressure prescribed by your doctor, or other medicines obtained from your drugstore without a doctor's prescription?
- Do you smoke?
- Have you had, or do you have, any disease of the liver or kidney?
- Is this headache different from your usual migraine attacks?
- Are you using Migranal  (dihydroergotamine mesylate, USP) Nasal Spray or other dihydroergotamine mesylate containing drugs on a daily basis?
- Are you taking a protease inhibitor for HIV therapy?
- Are you taking a macrolide class of antibiotic?
- Serious or potentially life-threatening reductions in blood flow to the brain or extremities have been reported rarely due to interactions between Migranal (dihydroergotamine mesylate, USP) Nasal Spray and protease inhibitors or macrolide antibiotics.
- REMEMBER TO TELL YOUR DOCTOR IF YOU HAVE ANSWERED YES TO ANY OF THESE QUESTIONS BEFORE YOU USE Migranal (dihydroergotamine mesylate, USP) NASAL SPRAY.
- Side Effects To Watch Out For
- In clinical trials, most migraine patients have used Migranal (dihydroergotamine mesylate, USP) Nasal Spray without serious side effects. You may experience some nasal congestion or irritation, altered sense of taste, sore throat, nausea, vomiting, dizziness, and fatigue after using Migranal (dihydroergotamine mesylate, USP) Nasal Spray. These side effects are temporary and usually do not require you to stop using Migranal (dihydroergotamine mesylate, USP) Nasal Spray. Although the following reactions rarely occur, they can be serious and should be reported to your physician immediately:
- Numbness or tingling in your fingers and toes
- Pain, tightness, or discomfort in your chest
- Muscle pain or cramps in your arms and legs
- Weakness in your legs
- Temporary speeding or slowing of your heart rate
- Swelling or itching
- Dosing Information
- Each vial contains one complete dose of Migranal  (dihydroergotamine mesylate, USP) Nasal Spray, which is 1 spray in each nostril followed in 15 minutes by an additional spray in each nostril, for a total of 4 sprays.
- Studies have shown no benefit from acute doses greater than 2.0 mg (4 sprays) for a single administration. The safety of doses greater than 3.0 mg in a 24 hour period has not been established.
- The safety of doses greater than 4.0 mg in a 7-day period has not been established.
Migranal  (dihydroergotamine mesylate, USP) Nasal Spray, should not be used for chronic daily administration.
- Learn what to do in case of an Overdose
- If you have used more medication than you have been instructed, contact your doctor, hospital emergency department, or nearest poison control center immediately.
- How to use the Migranal (dihydroergotamine mesylate, USP) Nasal Spray
- Use available training materials.
- Read and follow the instructions in the administration instructions which are provided with the Migranal  (dihydroergotamine mesylate, USP) Nasal Spray package before attempting to use the product.
- If there are any questions concerning the use of your Migranal  (dihydroergotamine mesylate, USP) Nasal Spray, ask your doctor or pharmacist, or call the Migranal  (dihydroergotamine mesylate, USP) Nasal Spray Information Line at 1-888-MY-RELIEF (1-888-697-3543) for training in the use of the spray.
- Check the contents of the package:
- 8 Nasal Spray Vials
- 8 Nasal Sprayers
- Package Insert
- Assemble the sprayer:
- Assemble your nasal sprayer only when you are ready to use it.
- Lift tab to bend back blue cover. In one piece, completely remove the blue cover and metal seal in a circular motion. Keeping the vial upright, remove rubber stopper. Set vial aside.
- Remove plastic cover from the bottom of pump unit. Insert spray pump into vial and turn clockwise until securely fastened.
- Using the sprayer:
- Remove cap from spray unit. Holding the vial upright, point nasal sprayer away from face and pump 4 times before using. DO NOT PUMP MORE THAN 4 TIMES. (Although some medication will spray out, there is enough medication in each vial to allow you to prepare your nasal spray pump properly and still receive a full treatment of MIGRANAL.)
- Spray once into each nostril. Do not tilt head back or sniff through your nose while spraying or immediately after. Wait 15 minutes. Spray once again into each nostril.
- After completing these instructions:
- Carefully dispose of the nasal spray pump with the vial.
Important Notes:
- Once a Migranal  (dihydroergotamine mesylate, USP) Nasal Spray vial has been opened, it must be thrown away after 8 hours.
- Storing Migranal (dihydroergotamine mesylate, USP) Nasal Spray
- Keep medication in a safe place away from children
- Keep Migranal  (dihydroergotamine mesylate, USP) Nasal Spray away from heat and light.
- Do not expose Migranal  (dihydroergotamine mesylate, USP) Nasal Spray to temperatures over 77F.
- Never refrigerate or freeze Migranal  (dihydroergotamine mesylate, USP) Nasal Spray.
- Do not keep an opened Migranal  (dihydroergotamine mesylate, USP) Nasal Spray vial for more than 8 hours.
- Check the expiration date printed on the vial containing medication. If the expiration date has passed, do not use it.
- Answers to patients' questions about Migranal (dihydroergotamine mesylate, USP) Nasal Spray
- What if I need help in using my Migranal (dihydroergotamine mesylate, USP) Nasal Spray?
- If you have any questions or if you need help in opening, putting together, or using Migranal (dihydroergotamine mesylate, USP) Nasal Spray, speak to your doctor or pharmacist, or call the Migranal (dihydroergotamine mesylate, USP) Nasal Spray Information Line at 1-888-MY-RELIEF (1-888-697-3543) or visit www.migranal.com.
- How much medication should I use and how often?
- Each vial contains one complete dose of Migranal (dihydroergotamine mesylate, USP) Nasal Spray, which is 1 spray in each nostril, followed by an additional spray in each nostril 15 minutes later for a total of 4 sprays. Do not use more than this amount unless instructed to do so by your doctor. Migranal (dihydroergotamine mesylate, USP) Nasal Spray is not intended for chronic daily use.
- Why do I have to prime or pump the Nasal Sprayer 4 times before using? Am I wasting the medication?
- You have to prime the Nasal Sprayer 4 times to make sure that you get the proper amount of medication when you use it. Although you will see some medication spray out, there is still enough medication in each vial to allow you to prepare your sprayer properly and still receive a full dose of Migranal (dihydroergotamine mesylate, USP) Nasal Spray.
- Can I assemble the medication vial and the Nasal Sprayer so it is ready before I need to use it?
- No. The brown (amber) glass vial containing your medication must remain unopened until you are ready to use it. It may not be fully effective if opened and not used within 8 hours.
- Can I reuse my Migranal (dihydroergotamine mesylate, USP) Nasal Sprayer?
- No. After completing the full dose, you must carefully dispose of your Migranal (dihydroergotamine mesylate, USP) Nasal Sprayer and the opened vial. You should use a new unit for your next migraine attack. Each Unit contains a new Nasal Sprayer, and a vial of Migranal (dihydroergotamine mesylate, USP) Nasal Spray medication.
- Can I use Migranal (dihydroergotamine mesylate, USP) Nasal Spray if I have a stuffy nose, cold, or allergies?
- Yes. Migranal (dihydroergotamine mesylate, USP) Nasal Spray can be used if you have a stuffy nose, cold, or allergies. However, if you are taking any medications for your cold, or allergies, even those you can buy without a doctor's prescription, speak with your doctor before using Migranal (dihydroergotamine mesylate, USP) Nasal Spray.
- Do I need to sniff the medication when I spray it in my nostril?
- No, you should not sniff because Migranal (dihydroergotamine mesylate, USP) Nasal Spray should remain in the nose so that it can be absorbed into the bloodstream through the lining of the nose. If you have any other unanswered questions about Migranal (dihydroergotamine mesylate, USP) Nasal Spray, consult your doctor or pharmacist.

# Precautions with Alcohol
- Alcohol-Dihydroergotamine (nasal) interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
- MIGRANAL

# Look-Alike Drug Names
There is limited information regarding Dihydroergotamine (nasal) Look-Alike Drug Names in the drug label.

# Drug Shortage Status

# Price