Ultra Famine has two attacks which it alternates between:
- Matches Isaac's vertical position and charges off screen. Appears from a random side of a screen and fires a spread of five lines of five projectiles towards Isaac before disappearing again. This attack is repeated five times.
- Moves across the screen from one side of the screen to the other, oscillating between the top and bottom of the screen. Ultra Famine spawns a swarm of Ultra Famine Flies behind itself as it moves. Each fly charges towards Isaac when he is close and continue to move in the same direction until disappearing off screen.
After dropping to 1/3rd of its max health, Ultra Famine loses its horse and body becoming only a head. In this phase, Ultra Famine only has one attack which it performs continuously from the center of the screen:
- Continuously fires projectiles in a counter-clockwise pattern, while simultaneously firing 6 bursts of projectiles outwards with alternating orientations.
- Ultra Famine, like the other Ultra Harbingers is an upgraded version of its regular counterpart, Famine.
- Unlike its lesser counterpart, Ultra Famine has no red pupils.
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