Pediatric Neurology xxx (xxxx) xxx

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Pediatric Neurology
journal homepage: www.elsevier.com/locate/pnu

Clinical Letter

Ischemic Stroke Following Ergotamine Overdose
Nadja F. Bednarczuk, BSc, MBBS, Ming Lim, MD, PhD, Ata Siddiqui, MD,
Karine Lascelles, MD *
Department of Paediatric Neurosciences, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners AHSC, London, UK

a r t i c l e i n f o
Article history:
Received 14 June 2019
Accepted 29 July 2019
Available online xxx

The use of ergotamine in the treatment of migraine has become
disputed because of its significant side effects, such as arterial vasospasm particularly affecting the peripheral arteries.1 However, there is
conflicting evidence about the effect of ergotamine on cerebral blood
flow.2-4 At present, ergotamine continues to be utilized, albeit offlicense, for the treatment of refractory migraine in pediatric patients.5 Yet, there is a lack of evidence supporting ergotamine's utility
and safety in migraine treatment.5 We describe a cerebral infarction
following an overdose of ergotamine in a seven-year-old boy, highlighting ergotamine's potential adverse effects on cerebral circulation.
Patient description
This seven-year-old boy presented with acute left-sided weakness and double vision with a preceding history of a mild illness,
lethargy, and acute-on-chronic headaches, for which he had been
prescribed dihydroergotamine (2 mg/mL). He was given 15 mL
(30 mg) orally in total over three days at home, with no treatment
precautions in place; this represents a significant overdose, as the
suggested dihydroergotamine dosing regimens for inpatient
migraine treatment in children younger than nine years is 0.5 mg
every eight hours to a maximum of 20 doses (10 mg total).6 He was
not taking other migraine treatments in conjunction with
dihydroergotamine.
On examination, he exhibited left hemiplegia and reduced power (Medical Research Council scale: 3 to 4/5) in the right arm and
leg. In addition, left fourth, fifth, sixth, and seventh cranial nerve
palsies were present. Reflexes were absent in the left leg and were

* Communications should be addressed to: Dr. Lascelles; Paediatric Neurosciences; Evelina Children's Hospital at Guy's and St Thomas' NHS Foundation Trust;
King's Health Partners Academic Health Sciences Centre, London SE1 7EH, UK.
E-mail address: Karine.Lascelles@gstt.nhs.uk (K. Lascelles).

brisk in the left arm. Peripheral pulses were palpable, and the patient was normotensive. A full stroke evaluation was completed and
ruled out other causes of infarction, such as thrombophilia risk
factors. Magnetic resonance imaging revealed bihemispheric white
matter lesions localizing to cerebral watershed zones and the
cerebellar hemisphere distributed in a parasagittal location (Fig).
Discussion
Migraine affects up to 10% children older than five years and can
prompt visits to the emergency department for their severity.5 Of
these acute presentations, 7% children fail current first-line therapies
and require inpatient rescue treatment, such as sodium valproate
and ergotamine.5-7 Historically, ergotamine was a first-line agent in
migraine therapy, but its use has become restricted to inpatient
treatment-resistant migraine. Despite being commonly utilized in
refractory pediatric migraine, its use remains off-label largely owing
to the lack of research supporting its utility and side effects,
including nausea and importantly arterial vasospasm.1,5,6
However, the effect of ergotamine on cerebral blood flow remains unclear. The majority of studies have reported unchanged
cerebral blood flow following ergotamine administration in both
healthy controls and migraineurs2,3; this is contrasted by one study
highlighting a reduction in cerebral blood flow.4 Similarly to our
patient, a single case report has linked high-dose, migraine-related
ergotamine use to cerebral infarction in a 50-year old female.8
It is important to consider that migraine itself is considered an
independent risk factor for stroke in adults.9 In contrast, childhood
migraine has not been linked to pediatric stroke, although there appears to be some increased risk of ischemic stroke in adolescents with
migraine.9,10 Therefore the main risk for cerebral infarction in our
patient remains the use of ergotamine in the setting of a mild preceding illness, potentially associated with a degree of dehydration.

https://doi.org/10.1016/j.pediatrneurol.2019.07.016
0887-8994/© 2019 Elsevier Inc. All rights reserved.

Please cite this article as: Bednarczuk NF et al., Ischemic Stroke Following Ergotamine Overdose, Pediatric Neurology, https://doi.org/10.1016/
j.pediatrneurol.2019.07.016

2

N.F. Bednarczuk et al. / Pediatric Neurology xxx (xxxx) xxx

Figure. Top row: Axial T2-weighted, diffusion-weighted images (DWI) and apparent diffusion coefficient (ADC) maps showing acute infarcts in the deep white matter of the
centrum semiovale in the parasagittal watershed and borderzone territories of the cerebral hemispheres demonstrating high signal on T2-weighted DWI images and corresponding
low signal on the ADC map. Bottom row: Follow-up magnetic resonance imaging done three months later showing expected evolution of the infarcts with volume loss and
encephalomalacia.

Conclusion
We suspect that the powerful vasoconstrictive effects of ergotamine,1 possibly confounded by dehydration, resulted in a significant reduction in cerebral blood flow and consequently infarction
in our patient. Clinicians should be aware of the potential risks
associated with ergotamine use. These risks can be minimized by
ensuring appropriate pretreatment precautions, such as adequate
hydration, patient monitoring during treatment, and prompt
management of associated side effects such as nausea and
vomiting.5

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Please cite this article as: Bednarczuk NF et al., Ischemic Stroke Following Ergotamine Overdose, Pediatric Neurology, https://doi.org/10.1016/
j.pediatrneurol.2019.07.016