the use of ergotamines causing ischemia of peripheral vessels has been reported , particularly in patients with peripheral vascular disease . ischemic bowel induced by ergotamines is a much rarer event , with few documented cases in the literature . while colitis is always on the differential diagnosis of hospital patients with abdominal pain , the majority of cases are secondary to infectious colitis associated with antibiotic therapy . when suspected , non - occlusive mesenteric ischemia can be treated with anti - coagulation and blood pressure support with intravenous fluids . the predisposition for ischemia in patients with chronic constipation secondary to opioid use is amplified by concomitant use of vasoactive medications to control symptoms of migraine headache . while abdominal ct scanning is frequently used to assess colonic pathology , findings often lag behind those identified at the time of colonoscopy . patchy areas of ischemia are often managed non - surgically by discontinuing the offending medication . widespread necrosis , coupled with clinical deterioration , as in this case , mandated immediate surgical intervention to prevent irreversible septic shock . a 48-year - old woman with a long - standing history of intractable migraine headaches was admitted to our institution 's specialty headache unit for aggressive management . she had no known history of peripheral vascular or cardiac disease but has been admitted multiple times for treatment of her headaches since her initial diagnosis in 2003 . during the course of each of these hospitalizations , she had received one to two courses of dihydroergotamine mesylate ( dhe ) 45 . during this admission she received two courses of dhe 0.5 mg  1 , then 1 mg every 8 h for a total of eight doses , on days 13 and the second course of therapy on days 79 . several hours after the final dose of her second round she became obtunded , minimally responsive and hypotensive with a blood pressure of 80/45 mm hg . on physical examination her abdomen was moderately distended with few bowel sounds . mmol / l , white blood cell count was 18.0 ( with 17% bands ) , and stool was clostridium difficile negative . the patient was transferred to the intensive care unit , given intravenous fluid boluses , started on vasopressors , and given broad spectrum antibiotics . her chest radiograph was unremarkable , and her abdominal x - rays showed only mild prominence of the colon . over the next several hours she became progressively acidotic with a worsening bandemia . a bedside colonoscopy showed diffuse ischemic colitis with fecal impaction and no pseudomembranes ( fig . operative findings showed a peritoneal cavity filled with murky , foul - smelling fluid and gangrene of the descending colon was seen with necrosis in the area immediately distal to the splenic flexure to the sigmoid colon . final pathology on the surgical specimen showed 86 cm of patchy , dark green / black large bowel , consistent with ischemic necrosis . the final diagnosis was gangrenous large bowel , ischemic colitis with thrombi or emboli noted . a hypercoaguable panel was performed following the operation and the patient was negative for clotting disorders . the differential diagnosis of ischemic colitis includes arterial occlusion , caused by emboli or thrombus , venous thrombosis , and non - occlusive ischemia caused by systemic hypotension or , as is strongly suspected in this case , ergotamine - induced vasospasm . a diagnosis of ergotamine - induced vasospasm is a diagnosis of exclusion , made when all other etiologies of ischemia have been ruled out . in this case , an arterial occlusion is unlikely , because there was no palpable thrombus and there was no clear ischemic demarcation to suggest a major vessel distribution . the patient had no history of cardiac arrhythmias , such as atrial fibrillation , to predispose her to emboli . furthermore she was a non - smoker and had no other cardiac risk factors such as atherosclerosis or hyperlipidemia . emboli to inferior mesenteric artery ( i m a ) are exceedingly rare , and there are no reported cases of spontaneous emboli or thrombosis to i m a . all reported cases of i m a thrombosis are subsequent to trauma [ 1 , 2 ] . venous thrombosis as a cause of ischemia in this patient is equally unlikely as there were no signs of venous congestion or stasis at the time of surgery . the patient had no hypercoagulable disorder and on examination the colon was not edematous and no clot was identified in the vasculature . ischemia secondary to systemic hypotension alone would have resulted in a watershed - type distribution of gangrene . in this case the most probable cause of this event was non - occlusive mesenteric ischemia in the i m a distribution and more specifically the left colic artery due to intense vasoconstriction induced by high - dose ergotamine use . underlying bowel wall distention from the impacted stool in combination with vasoconstriction from ergotamine is the most likely etiology for this patient 's bowel ischemia . dhe is indicated for the acute treatment of migraine headaches with or without aura and the acute treatment of cluster headache episodes . its therapeutic activity in the treatment of migraine headaches is generally attributed to the agonist effect at 5-ht1d receptors . according to the neurovascular theory of migraine , it is hypothesized that activation of 5-ht1d receptors on intracranial blood vessels leads to vasoconstriction . the 5-ht1d receptors on sensory nerve endings of the trigeminal are also activated , causing inhibition of pro - inflammatory neuropeptide release . ergotamine and dhe cause vasoconstriction of both arteries and veins due to alpha - adrenergic agonistic action , and they may also have possible interaction with prostaglandins , calcium and serotonin . dhe was developed in 1943 for migraine prophylaxis and shown in four studies in 1987 and five studies in 2001 to have less effect on peripheral arteries than ergotamine . as indicated in this case a european consensus report in 2000 concluded that ergotamine is not a drug of first choice in the triptan era , but may be useful in longstanding migraine attacks with multiple recurrences . ergotamine is known to cause peripheral ischemia , as has been reported in several case studies , most commonly in the lower limbs [ 5 , 6 , 7 , 8 , 9 ] . a causal relationship has not however been clearly established and is still the subject of some debate . other reports of ergotamine causing ischemic bowel appear in the literature [ 13 , 14 , 15 ] . in previous reported cases of colitis , expectant management with this is the first reported cases of ischemia progressing to gangrene such that colon resection was required . it should be noted in this case that the patient 's dose of dhe was greater than the recommended amount . the recommended dosing of dhe 45 is 1 mg iv / im / sc , repeated once every 24 h for a total dose not to exceed 6 mg in 7 days . in this case , the patient received 17 mg of dhe over the course of 9 days . although ischemic colitis is considered a rare side effect of high - dose ergotamine use , it is a very real risk of which clinicians need to remain aware . this is the fourth reported case of ischemic colitis secondary to high - dose ergotamine use reported in the literature and the first to require colon resection . while dhe can be useful in patients with refractory migraines , patients should be informed of the risks of both peripheral and visceral ischemia before deciding on this treatment . finally , ischemic colitis should be considered in the differential diagnosis of all patients taking ergotamines who present with abdominal pain .
a 48-year - old woman with a history of chronic migraines , initially admitted for inpatient management of intractable migraine headaches , developed new onset abdominal pain , hypotension , and diarrhea on hospital day number ten . in our institution 's headache unit , 
 patients are treated by a multidisciplinary approach , including individualized drug therapy based on diagnosis and previous response to therapy . 
 given the patient 's hypotension and clinical appearance , she was transferred to the intensive care unit and treated for septic shock and metabolic acidosis . 
 a bedside colonscopy revealed diffuse ischemic colitis . 
 final pathology after colon resection showed widespread , transmural necrosis of the colonic wall . 
 we review the pathophysiology of ergotamine use and its potential association with ischemic colitis .