Hello, I said I would report back after I saw the specialist again. (My previous post detailing my history is in the "Getting to know ya" thread.) As I said last week, I am now getting 4 CH's a day, and that would be even more if I didn't take a sumatriptan tab as a preventive 30 minutes before bed. I know this is not ideal, but I am at the point where I just need that 6 hours of solid sleep. What my doctor has done yesterday is increased my verapamil to dose (80mg 3x day & 160mg before bed) He has advised me to cut my topamax dose in half for 3 days, then stop it altogether. On the 4th day, I'm to begin 500 mg of depakote for 1 week then 1000mg depakote beginning the 2nd week. Then i will go for a depakote blood test, & he will see about increasing it to 1500mg. In the meantime he will call the pain management specialist to find out if one of my treatments included an Occipital nerve block, because I honestly can't recall if he injected around that area. I just remember quite a few injections all around my head. (It was 9 years ago & I was pregnant & in very bad shape with the headaches). If anyone here has had any relief using depakote, please can you tell me how long it took before you started seeing an improvement? I use imitrex injections (half a shot) for each daytime hit right now & I'm running low. I was only in there for about 20 minutes though, & I didn't really get a chance to ask him about a few things I had wanted to. But I will be going back next week, or in about 10 days.

Appears that you doc has some organized plan in play. But it will take time to adjust both meds & dosing to see what works for you.

Your Verap dose is at the lower end of the range which many folks find effective. I assume he is willing to step it up as your resonse indicates. Suggest you print out he following and use as a tool to discuss his plans and get his response to this approach.
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Headache. 2004 Nov;44(10):1013-8.   


Individualizing treatment with verapamil for cluster headache patients.

Blau JN, Engel HO.


    Background.-Verapamil is currently the best available prophylactic drug for patients experiencing cluster headaches (CHs). Published papers usually state 240 to 480 mg taken in three divided doses give good results, ranging from 50% to 80%; others mention higher doses-720, even 1200 mg per day. In clinical practice we found we needed to adapt dosage to individual's time of attacks, in particular giving higher doses before going to bed to suppress severe nocturnal episodes. A few only required 120 mg daily. We therefore evolved a scheme for steady and progressive drug increase until satisfactory control had been achieved. Objective.-To find the minimum dose of verapamil required to prevent episodic and chronic cluster headaches by supervising each individual and adjusting the dosage accordingly. Methods.-Consecutive patients with episodic or chronic CH (satisfying International Headache Society (IHS) criteria) were started on verapamil 40 mg in the morning, 80 mg early afternoon, and 80 mg before going to bed. Patients kept a diary of all attacks, recording times of onset, duration, and severity. They were advised, verbally and in writing, to add 40 mg verapamil on alternate days, depending on their attack timing: with nocturnal episodes the first increase was the evening dose and next the afternoon one; when attacks occurred on or soon after waking, we advised setting an alarm clock 2 hours before the usual waking time and then taking the medication. Patients were followed-up at weekly intervals until attacks were controlled. They were also reviewed when a cluster period had ended, and advised to continue on the same dose for a further 2 weeks before starting systematic reduction. Chronic cluster patients were reviewed as often as necessary. Results.-Seventy consecutive patients, 52 with episodic CH during cluster periods and 18 with chronic CH, were all treated with verapamil as above. Complete relief from headaches was obtained in 49 (94%) of 52 with episodic, and 10 (55%) of 18 with chronic CH; the majority needed 200 to 480 mg, but 9 in the episodic, and 3 in the chronic group, needed 520 to 960 mg for control. Ten, 2 in the episodic and 8 in the chronic group, with incomplete relief, required additional therapy-lithium, sumatriptan, or sodium valproate. One patient withdrew because verapamil made her too tired, another developed Stevens-Johnson syndrome, and the drug was withdrawn. Conclusions.-Providing the dosage for each individual is adequate, preventing CH with verapamil is highly effective, taken three (occasionally with higher doses, four) times a day. In the majority (94%) with episodic CH steady dose increase under supervision, totally suppressed attacks. However in the chronic variety only 55% were completely relieved, 69% men, but only 20% women. In both groups, for those with partial attack suppression, additional prophylactic drugs or acute treatment was necessary. (Headache 2004;44:1013-1018).

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SLOW-RELEASE VERAPAMIL

Dr. Sheftell applauded the protocol for verapamil used by Dr. Goadsby and colleagues, which entailed use of short-acting verapamil in increments of 80 mg. “This method was suggested by Lee Kudrow, MD, 20 years ago as an alternative to slow-release verapamil,” Dr. Sheftell noted.

“I would agree with using short-acting verapamil, rather than the sustained-release formulation, in cluster headache,” he said. “I prefer the short-acting formulation with regard to ability to titrate more accurately and safely. My clinical experience anecdotally demonstrates improved responses when patients are switched from sustained-release verapamil to short-acting verapamil.”

Dr. Goadsby agreed that his clinical experience was similar. “There are no well-controlled, placebo-controlled, dose-ranging studies to direct treatment. This is one of those areas where clinicians who treat cluster headache have to combine what modicum of evidence is available with their own clinical experience,” Dr. Sheftell commented.
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Dont do this without his O.K.: using Melatonin at night (9-11mg) is helpful to ward off night attacks as is 2mgSL tab of ergotamine. (Don't know if ergot. is  back on the market but if it is, it will block night attacks.)