To review the safety and efficacy of inpatient dihydroergotamine (DHE) infusion in refractory chronic migraine (rCM) patients with vascular risk factors.

Repetitive/scheduled (every 8 hours) DHE infusion is part of the standard-of-care protocol for inpatient migraine treatment. Due to its vasopressor effect, some practitioners avoid DHE in patients with vascular risk factors. We aim to investigate the safety and efficacy of DHE infusion in such population.

Retrospective chart review was performed on patients hospitalized in our Inpatient Headache Unit from 1/1/2019-5/1/2019. Inclusion criteria were diagnosis of rCM, men over 45 or women over 50 (corresponding to increased cardiovascular risk), and IV DHE use. Demographic data collected were age, sex, and vascular risk factors. Numerical pain rating score (NRS), dose/duration of DHE, mean arterial pressure (MAP), and adverse events (AEs) were collected for analysis.

Forty-six patients, age 57±7.7 (46-70) in men, 58±5.6 (51-69) in women were included. Vascular risk factors were BMI >24.9 in 31 (67.4%), hypertension in 15 (23.4%), hyperlipidemia in 14 (21.9%), smoking in 11 (17.2%), diabetes in 7 (10.9%), ischemic stroke in 4 (6.3%), CAD in 3 (4.7%), DVT/PE in 1 (1.6%). The mean maximum DHE dose was 0.83±0.23mg, with 28 (60.1%) reaching of maximum of 1mg. Infusion duration was 5.5±1.8 (1-9) days. NRS reduced from 7.0±2.2 on admission to 1.9±2.6 on discharge. Forty-four (95.7%) had pain reduction with 23 (50%) discharged headache-free. MAP was 90±12 mmHg on admission, 104±12 mmHg at a maximum during hospitalization, and 89±10 mmHg on final day of infusion. Five patients (7.8%) required additional antihypertensives and 3 (6.5%) required ³ 2 antiemetics. Three patients (6.5%) experienced intractable AEs requiring discontinuation of DHE (nausea in 2; hypertension in 1). No significant EKG change was observed.

When used in a monitored setting, repetitive DHE infusion is safe and effective in patients with vascular risk factors.