How to Help Your Patients Find D.H.E. 45 in Stock: A Provider's Guide

For providers managing patients with migraine and cluster headache, the ongoing D.H.E. 45 shortage is not just a supply chain issue — it is a clinical problem that falls to you to solve. Patients often turn to their prescribers when pharmacies come up empty, and without a structured plan, these situations become urgent and stressful for everyone. This guide provides practical, actionable strategies for helping your patients access dihydroergotamine mesylate — or an appropriate alternative — in 2026.

Step 1: Build a DHE Shortage Protocol Into Your Practice

The most effective approach is proactive, not reactive. Practices that have established protocols for the shortage experience fewer emergency calls and treatment gaps. Consider implementing the following:

Flag all active DHE patients in your EHR for shortage counseling at next visit.

Co-prescribe a backup medication (triptan or gepant) with clear patient instructions: use if DHE is unavailable.

Create a patient handout explaining the shortage, how to search for pharmacies with stock, and who to call for help.

Designate a staff member to monitor ASHP shortage updates and brief the prescribing team weekly.

Step 2: Know Which DHE Formulations Are Available

While the generic injectable (1 mg/mL ampules) is in shortage, other DHE formulations may be more accessible for your patients:

Brekiya (dihydroergotamine SC autoinjector, 1 mg) — FDA approved 2025. Single-use pen; does not require refrigeration, assembly, or priming. Comparable subcutaneous dosing to the injectable. Best for patients who previously self-injected.

Trudhesa (dihydroergotamine nasal spray, 0.725 mg/spray) — Higher-dose nasal delivery using POD technology. Suitable for patients who can use intranasal administration. Distributed through specialty pharmacy networks — more consistent supply.

Generic DHE nasal spray (Migranal, 0.5 mg/spray) — Separate supply chain from the injectable; may be available when the injection is not.

Step 3: Work With Specialty Pharmacies

Brand-name DHE products (Trudhesa, Brekiya) are distributed primarily through specialty pharmacy networks. These networks often maintain more reliable inventory than retail chain pharmacies during shortages. Establishing a working relationship with one or two specialty pharmacies that stock DHE products benefits your whole patient panel.

When sending prescriptions for these products, send them directly to the specialty pharmacy rather than to a retail pharmacy. This streamlines the process and reduces patient frustration when retail pharmacies report it's unavailable.

Step 4: Navigate Prior Authorization for Brand DHE Products

Brand formulations like Trudhesa and Brekiya often require prior authorization. The active shortage of the generic injectable is a strong basis for medical necessity. When submitting PAs:

Reference the ASHP shortage listing (created August 8, 2024; updated August 28, 2025) for generic dihydroergotamine mesylate injection.

Document that the patient's regular pharmacy has been unable to supply the generic injection due to the national shortage.

Specify that the brand formulation is the only currently accessible form of the same drug.

Many plans will approve a shortage exception faster than standard step therapy — frame it as a shortage exception, not a brand preference.

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Step 5: Direct Patients to Pharmacy Search Tools

One of the highest-leverage things you can do during a shortage is direct patients to a pharmacy search service. medfinder for providers allows you to recommend a service that calls pharmacies near the patient to find which ones have DHE in stock. Instead of patients calling 10 pharmacies and getting nowhere, medfinder does the legwork and texts them the results. This reduces patient distress and the volume of urgent calls to your office.

Step 6: Counsel Patients on What to Expect

Patients who understand the shortage are less likely to panic or delay seeking help. Key talking points:

"The generic injectable D.H.E. 45 is in national shortage. This is not your pharmacy's fault and there is nothing wrong with your prescription."

"Start looking for your refill at least 2 weeks before you run out."

"Try independent pharmacies and specialty pharmacies — they sometimes have stock when chains don't."

"If you absolutely cannot find it, use your backup prescription and call us."

For a deeper clinical overview of the shortage, see our article on what providers need to know about the D.H.E. 45 shortage in 2026.