Efficacy of Repetitive Intravenous Dihydroergotamine for Pediatric Refractory Migraine

Repetitive intravenous dihydroergotamine (DHE) may be an effective abortive therapy for children with status migrainous or chronic migraine, but has no lasting benefit, according to study results published in Headache.

While intravenous DHE was previously suggested to be effective for children with migraine who were resistant to outpatient treatments, limited data are available on the recommended protocol. The objective of this study was to review the local experience with repetitive intravenous DHE in children and identify the recommended protocol. Furthermore, the study researchers investigated the benefits of completing all 8 or 9 doses of DHE, as specified in the institutional protocol.

This retrospective study included 159 children (≤18 years of age; mean age at admission, 15 years; 67% girls) who received intravenous DHE while admitted at University of Virginia Children’s Hospital between January 1, 2011 and January 1, 2019. Of these, 78 (49%) were diagnosed with chronic migraine, 70 (44%) had status migrainosus, and the remainder 11 patients (7%) had other headache with migrainous features. Study researchers recorded patient-reported pain scores on admission and discharge. Follow-up outcomes were categorized as headache freedom, over 50% relief, less than 50% relief, or no relief.

A total of 60 patients (38%) completed the full course (8 or 9 doses) of DHE. Of those who did not complete DHE protocol, 65 patients (66%) discontinued treatment after achieving headache freedom, 14 patients (14%) stopped treatment due to side effects or intolerance, and 18 patients (18%) stopped treatment due to patient preference.

At discharge, headache freedom was recorded in 96 patients (60%). There was no difference in relative change in headache between patients with status migrainosus, those with chronic migraine, and those with other headaches with migrainous features.

Patients who completed the full course of DHE were more likely to have persistent headache at the time of discharge, compared with those who did not complete the DHE protocol (median pain score, 1.0 vs 0.0, respectively; P <.001). The relative change in headache was greater in the DHE incomplete group, compared with patients who completed DHE. Similarly, the rate of headache freedom at discharge was greater in the DHE incomplete than complete group (73% vs 40%, respectively; P <.001). No difference, however, was found in pain relief outcomes at follow-up between the two groups.

The study had several limitations, including the retrospective design, limited scope of the analysis, the use of subjective classification, and unaccounted for sources of variability.

Study researchers concluded that their data supports “the efficacy of repetitive IV [intravenous] DHE as an abortive therapy for refractory migraine in the pediatric population, both for status migrainosus and CM [chronic migraine]. However, in our cohort, no clear sustained benefit at follow-up was demonstrated, and there was no difference in pain relief at follow-up between patients who completed the full 8 or 9 doses of DHE and those that did not.”

Reference

Theroux LM, Cappa R, Mendoza A, Mallawaarachchi I, Samanta D, Goodkin HP. Implementation of an intravenous dihydroergotamine protocol for refractory migraine in children. Headache. Published online, August 27, 2020). doi: 10.1111/head.13937