A systematic review7 revealed that dihydroergotamine (DHE) alone was less effective than subcutaneous sumatriptan in migraine pain reduction (OR=0.44; 95% CI, 0.25–0.77) or headache resolution (OR=0.05; 95% CI, 0.01–0.42). No differences were seen between DHE alone and chlorpromazine or lidocaine. Three studies revealed DHE plus metoclopramide was more effective than or equal to other agents for headache pain reduction at 2 hours: one vs ketorolac IM (OR=7; 95% CI, 0.86–56.89), one vs meperidine (Demerol) plus hydroxyzine (Vistaril, Atarax) IM (OR=47.67; 95% CI, 4.32–526.17), and one vs valproate IV (OR=0.67; 95% CI, 0.19–2.33).7 Specifically, treatment with DHE plus metoclopramide was superior to ketorolac for pain reduction (P=.03), but patients did not differ in disability scores (P=.06). DHE plus metoclopramide achieved greater reductions in pain scale scores than meperidine plus hydroxyzine (P<.001). No significant difference in pain reduction was noted between DHE plus metoclopramide and valproate (P=.36).
A multicenter, double-blind, randomized parallel group study8 showed no difference between the combination product isometheptene mucate, dichloralphenazone with acetaminophen (Midrin, Duradrin, etc) (used as recommended in the package insert with a maximum of up to 5 tablets within 24 hours) vs oral sumatriptan (initial dose of 25 mg with a repeat 25 mg dose in 2 hours). No placebo arm was used in this study.
Recommendations from others
The Institute for Clinical Systems Improvement recommends the use of vasoactive drugs over narcotics and barbiturates for treatment of moderately severe migraine headaches.9 The American Academy of Neurology recommends migraine-specific medications (triptans, DHE) for moderate to severe migraines or those mild to moderate migraines that responded poorly to NSAIDs or other over-the-counter preparations.10