Written by: Utkarsha Patil (M.Pharm., Pharmacology) and Shakuntala Kawhale (M.Pharm., Pharmacology)
The U.S. Food and Drug Administration (FDA) have approved Atzumi (dihydroergotamine mesylate) nasal powder for the acute treatment of adult migraine with or without aura, marking a major breakthrough in migraine care. This approval offers millions of migraine sufferers’ quick and efficient relief by introducing a new, non-invasive delivery method for a proven migraine medication. However the approval comes with some limitations like it is not indicated for preventive treatment of migraine or for the management of hemiplegic migraine or migraine with brainstem aura. Satsuma pharmaceuticals are known for their innovative products have been given this landmark approval by FDA. Atzumi has been developed on the SMART platform (Simple Mucoadhesive Release Technology) which uses to combines a proprietary advanced powder and device technology to simplify delivery of medicine.
Migraine and Need of the Novel Therapy
Migraine is defined as a severe, throbbing, and unilateral headache that is usually associated with photophobia (light sensitivity), phonophobia (sound sensitivity), nausea, and vomiting. It is generally considered a neurological disorder that comes in episodic attacks or presents in chronic form with or without aura.
Conventional therapy for migraine includes acute and preventive (prophylactic) treatment with various drug classes used depending on the frequency and severity of attacks. Like NSAIDs, triptans, ergotamines, and antiemetics. Preventive therapy includes anti-seizure drugs, beta-blockers, calcium channel blockers, antidepressants, and Botox treatment.
Despite the availability of numerous medicines and these medicine have effect to minimise migraine to some extent, many patients still suffer from terrible side effects, treatment failure, or delayed relief.
Triptans, one of the most commonly prescribed classes, act as serotonin receptor agonists and work by causing vasoconstriction. However, this mechanism makes them unsuitable for individuals with cardiovascular disease. They are most effective when taken early during a migraine attack but can cause side effects such as dizziness, fatigue, and nausea. Additionally, frequent use can lead to rebound headaches or medication-overuse headaches (MOH).
NSAIDs are often used to relieve mild to moderate migraine pain, but they are typically ineffective for more severe attacks. Prolonged or frequent use can result in gastrointestinal complications, including ulcers and bleeding.
Antiemetics, which are used to alleviate nausea associated with migraines, can cause extrapyramidal symptoms such as dystonia and akathisia. They may also lead to sedation and, with long-term use, carry a risk of tardive dyskinesia.
Although Dihydroergotamine (DHE) has been used for decades to treat migraine attacks, it is associated with poor tolerability, variable absorption, and serious side effects like vasospasm and ischemia. Their use requires careful dosing to avoid toxicity.
Atzumi: A Novel Powdered Nasal Ingredient
FDA is approved Atzumi is a powdered nasal inhaler that delivers dihydroergotamine mesylate (DHE) in the form of a dry nasal powder. It provides migraineurs with a quick-acting, convenient, and needle-free alternative. Atzumi harbour various advantages over its older form of dosage and also over other therapies which includes Innovative Delivery System where it utilizes the SMART (Simple MucoAdhesive Release Technology) platform, combining advanced powder formulation with a proprietary nasal delivery device. This system ensures consistent and accurate dosing, enhancing drug absorption and patient convenience. Rapid and Sustained Absorption: Clinical studies demonstrated that Atzumi achieves rapid absorption, with mean DHE plasma concentrations of 2.0 ng/mL within approximately 15 to 20 minutes. This rapid onset is coupled with sustained plasma levels, providing prolonged relief from migraine symptoms. Improved Tolerability: Compared to injectable and liquid nasal spray forms, Atzumi’s dry powder formulation reduces issues like nasal dripping and throat irritation. Common adverse events were generally mild, including rhinitis, nausea, and altered taste. Ease of Use: The portable, single-use device allows for self-administration without the need for refrigeration, making it more accessible for patients. Non-Oral Administration: By bypassing the gastrointestinal tract, Atzumi avoids issues related to nausea and vomiting that can come with migraines, which often hinder the effectiveness of oral medications. Suitable for Triptan Non-Responders: For patients who do not respond to or cannot tolerate triptans, Atzumi provides an alternative with a different mechanism of action.
Hence, the approval of Atzumi marks an important milestone, offering a new option for the acute treatment of migraine that blends the long-established effectiveness of DHE with a user-friendly, convenient delivery system.
Ryoichi Nagata, Satsuma Pharmaceuticals said in a statement. “We believe that Atzumi will contribute to improving the quality of life of patients struggling for relief from these highly disabling problems.”
FDA Approval and Evidence from Clinical Trials
Even though DHE is in practice since long, Atzumi approval comes from rigorous clinical trials in which DHE underwent A Phase 1 pharmacokinetics (PK) trial and the Phase 3 open-label trials called ASCEND Trial, aassessed the long-term safety and tolerability of Atzumi in adults with migraine.
Phase 1 study (NCT03874832), is randomized, open-label, three-period crossover study that evaluated the pharmacokinetics, safety, and tolerability of STS101 (Atzumi), a dihydroergotamine (DHE) nasal powder, in 43 healthy adult volunteers. The study compared single doses of STS101 with intravenous (IV) DHE and DHE nasal spray, aiming to assess parameters like maximum plasma concentration (C_max) and time to reach maximum concentration (T_max). STS101 demonstrated rapid absorption, reaching effective plasma levels within 10 minutes, and achieved higher bioavailability than the DHE nasal spray. It also showed a favorable safety profile, with lower C_max than IV DHE, reducing the risk of nausea. These promising results supported the advancement of STS101 into later-phase trials, including the Phase 3 ASCEND study (NCT04406649).
The ASCEND trial (NCT04406649) was a Phase 3, open-label, multicenter study evaluating the long-term safety, tolerability, and exploratory efficacy of STS101 (Atzumi), for the acute treatment of migraine in adults aged 18 to 65 years. Participants with a history of migraine with or without aura self-administered STS101 as needed over a 12-month period, with some continuing up to 18 months. The study found that STS101 was well tolerated, with a low incidence of treatment-emergent adverse events (TEAEs), most of which were mild or moderate. Efficacy assessments showed that 36.6% of treated attacks achieved pain freedom at 2 hours post-dose, increasing to 85.5% at 24 hours. Additionally, freedom from the most bothersome symptom was reported in 54.3% of attacks at 2 hours, rising to 91.3% at 24 hours. The favorable safety and efficacy profiles observed in the ASCEND trial supported the FDA approval of Atzumi for the acute treatment of migraine with or without aura in adults.
Safety Profile
During clinical trials Atzumi shows common adverse reactions (incidence > 1%) including rhinitis, nausea, altered sense of taste, application site reactions, dizziness, vomiting, somnolence, pharyngitis, and diarrhea. However Atzumi carries a warning of serious drug interaction with strong CYP3A4 inhibitors where serious and potentially life-threatening peripheral ischemia has been linked to the combined use of dihydroergotamine and strong CYP3A4 inhibitors. These inhibitors can raise dihydroergotamine blood levels, increasing the risk of vasospasm, which may lead to cerebral or limb ischemia. Therefore, Atzumi should not be used in combination with strong CYP3A4 inhibitors.
Conclusion
Atzumi approval marks a significant advancement in migraine therapy by addressing the limitations of conventional DHE formulations. Unlike intravenous DHE, which requires administration in clinical settings and is often associated with nausea, or nasal sprays with inconsistent absorption, Atzumi delivers rapid, consistent, and sustained drug levels through a user-friendly nasal powder system. However, due to the risk of vasospasm and ischemia, Atzumi is contraindicated in patients taking strong CYP3A4 inhibitors, which can elevate DHE plasma concentrations. Overall, Atzumi provides an effective, non-invasive, and well-tolerated treatment alternative for patients seeking fast and reliable relief from migraine attacks, with clear advantages over traditional DHE therapies.
Referances
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