I am about to try verapamil for the first time as a prophylactic. However I note that there is a possible interaction between verapamil and aspirin.

I find aspirin very effective against low level headaches (say kip 4 or less). It really is my best friend for these mild to moderate headaches (useless for anything of around 5 or more though). My concern is that if I start the verapamil it may limit my use of aspirin. On the other hand if the verapamil works well hopefully I won't need aspirin!

From a bit of research the verapamil and aspirin interaction has two components:
- increased bleeding tendency eg bruising or prolonged bleeding time
- decreased antihypertensive effect (not relevant in my case)

I have two questions that lead on from this:

1. Has anyone any practical experience of using verapamil and aspirin together?

2. How long is it likely to take before the verapamil starts to work (assuming it will for me)?

Thanks for any advice.

Hi BlueDevil

I've not had issues with the verapamil / aspirin combination, although I've had very light aspirin use whilst on verapamil.

For verapamil itself it typically takes around 10 days for a dose level to become effective. So do not change doses more frequent than about every 2 weeks to give time for you to notice a real change.

Since verapamil dose levels normally start low and build up you may need to repeat this 2 week process a few times. An effective dose for many is 360-480mg a day although some people need up to 1000mg.

There are also differences of opinion over the use of the sustained release / standard release versions with some people finding one works much better than the other. Again an area for experimentation.

Watch out for the side effects, mainly from the reduction in blood pressure which can be an issue for those who already have a low blood pressure. I'm also convinced that concrete dust is included in the tablets from the effect it has on my digestive system.

Verapamil can also affect the PR interval (START PRINTPAGEMultimedia File Viewing and Clickable Links are available for Registered Members only!!  You need to or END PRINTPAGE) so most doctors will request ECGs at dose changes or every few months.

Before I was diagnosed with CHs I controlled the attacks with asprin. In my case, I'd chew them. Sometimes twice a day. It did help but it also created a nice little hole in my stomach as well. Verapamil did/is working for me so my asprin intake is limited to an 81mg "baby asprin" a day for artery health. How much asprin are we talking here for you? blessings. lance

Guideline is: any OTC pain med used to treat headache can increase the # of attacks and severity if used more than 3-4x/week.

Suggest stopping aspirin totally while getting started with the Verap. This will give you a clean use of V and judging it effectiveness/dose will be earier.
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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.