In migraine management, when are ergotamines considered?

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Ergotamines are older, second-line options for acute migraine relief. They’re not used as the first choice because of safety and tolerability concerns, and because triptans provide similar benefit with a more favorable risk profile. They may be considered when a patient has not responded to triptans or cannot take them, making them a backup option rather than a routine one. Ergotamines work by causing cranial vasoconstriction, which can abort an attack, but they carry risks such as ergotism from excessive vasoconstriction, nausea, and important drug interactions (for example with strong CYP3A4 inhibitors and other vasoconstrictors). They’re not appropriate for all patients and have several contraindications (vascular disease, pregnancy, significant hepatic/renal impairment), which further limits their use. In practice, they’re reserved for triptan-failure scenarios or when triptans are unsuitable.