Chronic use of ergotamine derivatives has been well described in the literature to cause retroperitoneal, pleural, pericardial and valvular fibrosis. While acute migraine treatment advances have resulted in a reduction of ergotamine derivatives prescribing, they are still considered appropriate for some patients. We report a case of diffuse pachymeningitis with symptomatic right sixth cranial nerve palsy who had a history of long-term Cafergot© suppository use. To the best of our knowledge, this is the first case to temporally associate ergotamine derivatives with pachymeningitis. [ABSTRACT FROM AUTHOR]