Migraine Headache Clinical Pathway — Inpatient

Dihydroergotamine Protocol (DHE)
Age, Years	Starting Dose	Dose Titration	Maximum Dose
6 – < 10 OR 25 kg	0.1 mg	If tolerated, increase by 0.1 mg every 8 hours until maximum dose or side effects occur	0.5 mg IV every 8 hours
≥ 10 – 12	0.2 mg	If tolerated, increase by 0.2 mg every 8 hours until maximum dose or side effects occur	1 mg IV every 8 hours
≥ 12	0.25 mg	If tolerated, increase by 0.25 mg every 8 hours until maximum dose or side effects occur	1 mg IV every 8 hours

Patients who have previously received DHE may start at 50% of previously maximally tolerated dose for one dose and then, if tolerated, increase to previously maximally tolerated dose

Continue DHE for at least 5 doses and up to 20 doses; if HA relief is achieved, give one additional dose

Complete any needed imaging prior to starting DHE

Please use intranasal DHE only if IV DHE is unavailable, or if the patient does not have IV access

Potential Medication Interactions with DHE

Triptans — DHE should not be given within 24 hrs of any triptan medication
Serotonin-modulating medications (including SSRIs, TCAs) — OK to continue these medications with DHE, but monitor for signs of serotonin syndrome
Beta-blockers — Hold beta-blockers while patient is receiving DHE
Midodrine — OK to continue, but monitor closely for blood pressure changes and worsening orthostatic intolerance. If patient is hypertensive, hold midodrine while giving DHE and for 2 days afterwards. If patient has worsened orthostatic intolerance, consider stopping DHE.
- See Lexicomp for full list of medication interactions

Insufficient Improvement after DHE
Insufficient improvement after 3 doses	Discuss nerve block with patient/family while continuing DHE View PFE for Nerve Block If interested in nerve block, contact Headache Team via email Consider adding one/both of the following for at least 2 doses for synergy with DHE: Valproic Acid Magnesium Sulfate
Insufficient improvement after 5 doses	Consider trial dose of Levetiracetam

Managing DHE Side Effects
Nausea/Vomiting	1st Line: Premedicate with Metoclopramide 0.1-0.2 mg/kg/dose (Max < 12 yrs: 10 mg, ≥ 12 yrs: 20 mg) 2nd Line: Ondansetron 0.1 mg/kg (Max 4 mg) q 8 hr PRN IV/PO (especially if need to stop Metoclopramide) 3rd Line: Diphenhydramine 1 mg/kg up to 25 mg q 8 hr PRN IV/PO 4th Line: Lorazepam 0.02-0.04 mg/kg/dose q 6 hr PRN IV/PO If significant nausea occurs with the first dose, decrease the dose by 50% and advance as tolerated.
Worsened Headache	Reduce dose of DHE to previously tolerated dose and advance as tolerated. If headache worsens significantly with the first dose, decrease the dose by 50% and advance as tolerated.
Muscle Cramping	PRN Lorazepam or Diazepam, consider premed before future doses. Reduce dose of DHE to the previously tolerated dose and advance as tolerated. If side effect occurs with the first dose, decrease the dose by 50% and advance as tolerated. Consider acute treatment of throat tightness or muscle spasm with a benzodiazepine and then premedicating future doses of DHE with an oral benzodiazepine 30 minutes prior to DHE.
Chest Pain	Check EKG immediately and repeat in 6 hours. If all labs are normal, consider restarting DHE at previously tolerated dose and advance as tolerated. If side effect occurs with the first dose, decrease the dose by 50% and advance as tolerated. If chest pain occurs, EKGs should be checked daily. DHE should be stopped if chest pain continues despite lower dose or if EKG shows signs of ischemia.
Vasospasm	Heat packs PRN, stop infusion if severe
Ergotism, DVT	Rare. Stop infusion/Discontinue DHE
Suggestions for Management of Adverse Effects

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.