Almotriptan × Ergotamine

Both drugs constrict arteries. Almotriptan stimulates serotonin receptors in cranial vessels and constricts them. Like other triptans, it can very rarely cause coronary artery spasm. Ergotamine constricts blood vessels and can cause myocardial ischaemia, or rarely infarction, even in people with no known heart disease. Vasospasm after ergot drugs can be prolonged. In a study of 12 healthy volunteers, oral almotriptan with ergotamine caused no extra vasospasm, but the vasoconstrictor effects may in theory add up.

Coronary artery spasm causes chest pain, pressure or tightness, sometimes severe and spreading to the throat, neck or jaw, and can lead to myocardial infarction. Vasospasm from ergotamine causes numbness and tingling in the fingers and toes, headache and pain over the heart. With severe spasm, the limbs turn blue and their pulses disappear. Spasm of the intestinal arteries causes abdominal pain with bloody diarrhoea. Sudden vision loss and stroke have been reported after triptans. Both drugs can raise blood pressure.

The almotriptan documents of the Spanish Agency of Medicines and Medical Devices (AEMPS) and the US Food and Drug Administration (FDA) contraindicate the combination. The Spanish summary of product characteristics (SmPC) for ergotamine with caffeine contraindicates all triptans (AEMPS). After ergotamine, wait at least 24 hours before taking almotriptan (almotriptan SmPC, AEMPS, and label, FDA). After almotriptan, the Spanish SmPC allows ergotamine after 6 hours, while the US label requires the same 24 hours (almotriptan label, FDA). If ergotamine has not stopped the attack, do not add a triptan for the same attack (ergotamine with caffeine SmPC, AEMPS). If chest pain or tightness appears after an almotriptan dose, withhold further doses and assess the patient for cardiac ischaemia (almotriptan SmPC, AEMPS). Stop ergotamine at once if numbness or tingling in the fingers, pain over the heart or other signs of vasospasm appear (ergotamine with caffeine SmPC, AEMPS). If abdominal pain with blood in the stool, white fingers or vision loss follow a dose, assess arterial blood flow (almotriptan label, FDA). Taking ergotamine, triptans or both on 10 or more days a month can cause medication overuse headache, with more frequent attacks (almotriptan label, FDA).