D.H.E. 45 Shortage: What Providers and Prescribers Need to Know in 2026

Dihydroergotamine mesylate injection (D.H.E. 45) has been on the ASHP drug shortage list since August 2024, with supply instability dating back to Bausch Health's discontinuation of the brand in 2022. For neurologists, headache specialists, emergency medicine physicians, and PCPs managing patients who rely on DHE, this shortage requires proactive clinical planning. This guide summarizes the current supply situation, clinical alternatives, and how to communicate effectively with patients.

Current Supply Landscape

As of 2026, the U.S. market for dihydroergotamine mesylate injection (1 mg/mL ampules) depends on two generic manufacturers:

Hikma Pharmaceuticals — Has product available but has experienced backorder periods.

Provepharm — Has product available; experienced a significant backorder in late 2024.

Perrigo has discontinued their formulation. Bausch Health discontinued the branded D.H.E. 45 in 2022. This leaves the entire market dependent on two suppliers — a structurally fragile supply chain for a drug that plays a critical role in refractory migraine and cluster headache protocols.

Clinical Context: Why DHE Matters

Dihydroergotamine mesylate is FDA-approved for acute treatment of migraine (with or without aura) and cluster headache episodes. Its clinical utility goes beyond what FDA labeling reflects:

IV DHE infusion protocols (repetitive IV DHE or "DHE protocol") are widely used off-label for status migrainosus and intractable headache in inpatient settings.

DHE has a notably lower headache recurrence rate compared to triptans due to its longer half-life and sustained vasoconstriction.

For patients with nausea and vomiting, parenteral DHE bypasses GI absorption issues that limit oral therapies.

DHE is one of the few options for patients who have failed multiple triptans or who need non-triptan parenteral therapy.

Alternative DHE Formulations to Consider

If the injectable is unavailable, the following DHE formulations retain the same active ingredient with different delivery mechanisms:

Trudhesa nasal spray (0.725 mg/spray) — Uses Precision Olfactory Delivery (POD) to deposit medication deep in the nasal cavity. Achieves higher plasma concentrations than standard nasal spray. Distributed via specialty pharmacies.

Brekiya subcutaneous autoinjector (1 mg) — FDA approved 2025. Single-dose prefilled pen for home use; no refrigeration, assembly, or priming required. Dosing: 1 mg SC; may repeat at 1-hour intervals, max 3 mg/day.

Migranal nasal spray / generic DHE nasal spray (0.5 mg/spray) — Generic available; may have separate supply availability from the injectable formulation.

Clinical Alternatives If DHE Is Not an Option

If no DHE formulation is accessible or appropriate, AHS guidelines support the following:

Subcutaneous sumatriptan (6 mg) — First-line acute migraine and cluster headache treatment; faster onset via SC vs. oral.

IV metoclopramide or prochlorperazine — Useful in ED/inpatient settings; effective for migraine and associated nausea.

IV valproate sodium — Option for acute migraine in the inpatient or ED setting.

IV ketorolac — Parenteral NSAID; useful adjunct for acute migraine pain.

Gepants (ubrogepant, rimegepant) — Oral CGRP receptor antagonists; appropriate for patients who cannot use vasoconstrictors.

High-flow oxygen (cluster headache) — 100% O2 at 7–10 L/min via non-rebreather mask; effective in approximately 50–60% of cluster headache attacks.

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Counseling Patients on the Shortage

Proactive communication reduces emergency visits and patient distress. Best practices:

Advise patients to begin searching for refills 2–3 weeks before they run out, not when they are out.

Prescribe a concurrent backup medication (triptan or gepant) for all DHE patients, clearly labeled as "backup for shortage."

Direct patients to specialty pharmacies for DHE products distributed through those channels (Trudhesa, Brekiya).

Recommend a pharmacy search service to reduce patient burden during shortage navigation.

medfinder offers a provider portal for recommending pharmacy search services to patients. Directing patients to medfinder helps them locate available stock without adding administrative burden to your practice.

Documentation and Prior Authorization Considerations

When prescribing alternative formulations like Trudhesa or Brekiya, prior authorization may be required. Document the active shortage as the clinical rationale for formulary exceptions. Include ASHP shortage notification dates and note that the generic injectable is unavailable or backordered. This strengthens PA submissions and appeals.

For more practical guidance on helping your patients access DHE, see our provider's guide to helping patients find D.H.E. 45 in stock.