Skip the ER: How to Manage Hard-to-Treat Migraine at Home

Disclaimer:  This blog is based on a recorded interview with Dr. Stewart Tepper, certified headache specialist & paid consultant for Amneal and Satsuma. It is part of an educational project sponsored by Amneal Pharmaceuticals & Impel Pharmaceuticals. The content was developed independently without sponsors’ input.

An ER visit to stop a debilitating migraine often means hours of blinding fluorescent lights, endless waiting, and multiple odors that can easily make the attack worse than before—but it doesn't have to be your default rescue plan! People with migraine often find themselves at the emergency room to find relief for hard-to-treat migraine attacks or status migrainosus (when the attack is over 72 hours). Treatment-resistant attacks include wake-up migraine, fast-escalating migraine, and menstrual migraine, to mention just a few. 

For years, the only real fix was a trip to the emergency room for an IV medication called DHE(opens in new tab) (dihydroergotamine), or struggling with DHE-45 injection vials, syringes, and often severe side effects at home.

Here's the good news: DHE now comes in patient-friendly formats that you can easily use at home! No ER visit, no waiting room, no blinding lights or smells, no IV. So let's talk about what it is, who it's for, and how to bring it up with your doctor.

What Is DHE, and How Does It Work?

DHE stands for dihydroergotamine. It's been used to treat migraine for decades (since 1946), and it works a little differently than other migraine medications.

Most acute migraine treatments target one pain pathway in the body. DHE works on several at once. That's part of why it tends to be so thorough. It doesn't just dull the pain; it can stop the migraine completely.

DHE also reaches migraine from more angles than some other treatments, including the kind of "stuck" pain that sets in when a migraine has been going for a while. Doctors call this ongoing pain, often with other accompanying symptoms such as allodynia, central sensitization(opens in new tab). This is when your body becomes extra sensitive to light, sound, and touch, and amplifies pain. DHE can calm this down, even when other medications can't.

One more thing worth knowing: DHE isn't taken as a pill. It's given as a nasal spray or an injection. This matters because when you're nauseous or throwing up, a pill may not stay down long enough to help. Nasal sprays and injections can also work faster. Home-use DHE brands include Brekiya and Trudhesa, with another novel format currently in clinical trials. 

Who Is DHE For?

DHE can work for any type of migraine, but often it's best use is for migraine attacks that are hard to treat(opens in new tab). You might be a good candidate for DHE if you deal with:

• Wake-up migraine: migraine attacks that are already in full swing the moment you open your eyes.
• Fast-escalating migraine: pain that ramps up quickly, before you have much of a chance to treat it early.
• Nausea or vomiting: which makes oral medications unreliable.
• Migraine attacks that keep coming back: regular medication seems to work but then the attack comes back.
• Menstrual migraine: which tends to last longer and be treatment resistant.
• Status migrainosus: a migraine that lasts more than 72 hours.

If any of these sound like your experience, DHE may be worth exploring, especially if your current medications aren't fully getting you back to normal.

“DHE is right at the top in terms of most useful acute treatments for migraine, and well worth exploring if you're having trouble with the simpler options for controlling your migraine symptoms. You don't need to use it for every attack. You could reserve it for the attacks that are hard to treat. It's really important to see if you can get access to it, if you think you're a good candidate.” - Dr. Stewart J. Tepper

When Should You Use DHE?

Your headache doctor can help you determine when it's best for you to use DHE based on your migraine attacks, but often it’s best for specific attacks: when you wake up with a migraine, throw up during one, or need backup because nothing else is working. It can also help even if you've already waited too long to treat. DHE tends to still work later into an attack, when other options may not.

If your current acute treatments are not getting and keeping you symptom-free, you may be at risk for migraine progression, also known as chronification. If migraine disease progresses, your attacks may become more frequent and severe, and harder to treat. Take the Migraine Treatment Optimization Quiz (opens in new tab)to see if you can benefit from an additional or different acute treatment. 

Talking to Your Doctor About DHE

DHE isn't as automatically prescribed as some other migraine medications, partly because it takes a bit more instruction to use and may need special approval (such as prior authorization) from your insurance. If you’re interested in exploring DHE as a treatment option, ask your headache doctor:

• "Am I a good candidate for DHE based on my migraine pattern?"
• "Does a non-oral treatment form make sense for me?"
• "How can we incorporate DHE into my Migraine Action Plan?"

If you don't already have a Migraine Action Plan (MAP), a simple written guide for what treatment to start and when, this is a great time to build one with your doctor. Download our free MAP template here.

Let your doctor know how migraine symptoms are impacting your life, which goes beyond how many headache days you have a month or how many attacks. Consider discussing:

• How often do you miss work or personal commitments because of migraine? 
• How many hours are spent in bed trying to reduce symptoms? 
• How are your personal relationships impacted? 

Your Next Step

You don't have to keep choosing between suffering through treatment-resistant migraine attacks or heading to the ER for relief. Talk to your headache doctor about DHE(opens in new tab), and ask whether it might be beneficial for you. It just might be the missing piece you've been looking for!

LET US KNOW! Are you interested in trying home-use DHE to avoid an ER visit? Have you tried DHE recently or in the past? Share your questions and comments below!

This article is for educational purposes only and should not be considered medical advice. 

This article is based on the written transcripts from our interview with Stewart Tepper, VP of Research at the New England Institute for Neurology and Headache in Stamford, CT, and Clinical Professor of Neurology at Dartmouth Geisel School of Medicine, NH. This article was formatted with help from Claude AI.