Ergotarnine Headache MGtaken for Temporal Arteritis Jacqueline M. S. Winterkorn, PhD, MD," Jeffrey G. Odel, MD,? and Myles M. Behrens, MDf Ergot alkaloids often are used to treat migraine headaches. Although dangers of ergot overuse have been known since the Middle Ages, patients using ergotamine still present with ergotism. We have seen 2 patients with migraines using ergotamine tartrate who were referred for temporal artery biopsy because of symptoms suggesting temporal arteritis but who were found to be suffering from ergotism. A 45-year-old woman had three weeks of increasingly intense headache, with throbbing of the left temporal artery, accompanied by nausea, dizziness, and tinnitus. Along with the new headache, she had noticed digital numbness. Since the age of 3 she had a history of classic migraine headache, which she treated during the previous year with Cafergot-PB suppositories, 2 mg (ergotamine tartrate and caffeine), at first symptomatically and then prophylactically. For 6 months she had used Cafergot-PB each night at bedtime. Unlike her usual migraine headaches, these new headaches were not relieved by ergotamine tartrate. She experienced some relief when she squeezed her left temple, where she had a swollen temporal artery. Erythrocyte sedimentation rate was 7. Decadron had been prescribed for temporal arteritis O n examination, the left temple was slightly tender. Swelling had resolved on steroids and she had a normal pulse. Neuro-ophthalmic examination was entirely normal. Cafergot and steroid were stopped. Headaches, temporal artery pain, and digital numbness resolved. A 50-year-old woman had 4 days of continuous pain behind her left eye, with paroxysms of pain shooting from the front of her left ear to her cheek. She complained of fatigue, jaw claudication, and scalp tenderness. Her left temporal artery was tender and pressing her left eye or temple gave relief. Erythrocyte sedimentation rate was 35. Temporal arteritis had been diagnosed and prednisone, 80 mg per day, was prescribed. The patient had a 15-year history of migrnne headaches, treated for several years with oral Cafergot, 1 mg. She had been using Cafergot prophylactically twice per day for a

month. Neuroophthalmic examination was normal. Ergotism was suspected. Cafergot and prednisone were stopped. All symptoms resolved within 2 weeks. These patients were referred for biopsy with the suspected diagnosis of temporal arterius. Although their symptoms suggested temporal arteritis, their youth made that diagnosis unlikely. Their use of Cafergot suggested the diagnosis of ergotism, which was confirmed when their symptoms abated with the withdrawal of ergotamine. Headache not only is present in migraine and temporal arteritis, but also can result from ergotism. Our patients fit the profile described by Rowsell and colleagues [l}, who studied migraine patients with ergotamine-induced headache. Most of their patients were middle-aged women, on moderate doses of ergotamine (10-14 mg per week) for less than 6 months. As with our patients, the majority of theirs experienced resolution of symptoms within 2 weeks of stopping ergotamine. The symptoms of chronic ergotism, like those of temporal arteritis, are due to ischemia. Peripheral vasoconstriction from ergotamine produces headache, nausea, weakness, muscle pain, angina, diminished arterial pulses, ischemc p a n in the distribution of the external carotid artery, and cold and numb extremities (which may blacken and turn gangrenous). Central nervous system ischemia may produce depression, drowsiness, confusion, and even tabes dorsalis and miosis { 2 ] . Thus, migraine, temporal arteritis, and ergotism may present similar or overlapping symptoms. When patients with a history of migraine develop new symptoms suggesting temporal arteritis, they should be questioned about their use of ergot alkaloids and a diagnosis of ergotism should be considered.

"North Shore University HospitalCornell Univwsity Medical College Manhasret, NY fHarkness Eye Institate Columbia-PresbyterianMedical Center Neu, York. N Y

Refrences 1. Rowsell AR, Neylan C , Wilkinson M. Ergotamine-inducedheadaches in migrainous patients. J Headache 1973;13:65-67 2. Gilman AG, Goodman LS, Gilman A. Pharmacological basis of therapeutics. New York Macmdan, 1986939-347

396 Copyright 0 1990 by the American Neurological Association