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Sumatriptan is NOT used to prevent attacks. Using 2x day for a number of days can lead to rebound for some people.

The Verap dose is low. Used as a preventive (and its' the most common used, effective, safe). Print the following and give to your doc.

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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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If he puts you on these higher doses he will be aware of keeping a eye open for side effects, but unless you have some heart disorder now, risk is low.
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The signs that the rebounds are tapering off is that the #of attcks dimish--no other clinical signs.

Hi jish,
this is one  :question where we are all different. My cycle
would begin Spring and Autumn like clockwork. Last for three
months, then go through a day with no attacks and i knew
the  [smiley=evil.gif] had gone for now.

Hoppy.

Hey Hoppy, yeah everyones seems to be different. Since i've been on Verapamil (even at this low dose) it's been pretty manageable and i haven't really experienced anything i'd call serious pain in a couple of weeks - more just a general discomfort pressure feeling in my head on the right side that can build up to a slight ache and the odd burning sensation style shadow.

I guess my cycles are milder than a lot of sufferers at this time and in this cycle.

One thing i don't understand from reading other peoples experiences on this forum is- Do a lot of people still experience high levels of pain despite taking large doses of Verapamil along with their abortive of choice well into their cycle?

Despite saying my cycle is milder than most- when it started this time and before effective preventatives and abortives were prescribed, i was seriously beginning to consider suicide when i was experiencing Kip 9/10 levels of pain, vomiting from pain, the pain hangovers. Which is a scary thing to think about but all i can say to people who feel like this - hang in there because it get's better.

Also quit smoking and drinking alcohol for the duration. Monk life is key. Well monks with prescribed preventative/abortive drugs and devices..Anyway Y'all know what i mean.

While Verap is the most overal effective prevent., there folks for whom it doesn't work. Then you start trying some of the alternatives.

There is also a small % of folks whose meds, having been successful for long periods, just stop working!!! Who knows why? Then you start trials of optional meds until something clicks.

See the PDF file, below, for alternatives.

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jish wrote,
Also quit smoking and drinking alcohol for the duration. Monk life is key. Well monks with prescribed preventative/abortive drugs and devices..Anyway Y'all know what i mean.

Hi jish,
Yes smoking, although not proven as a trigger.
Smoke from cigarettes is known as a trigger in some folk, but smoking will certainly intensify the pain during a CH attack. Alcohol is a known trigger in most of us, but i know
of some lucky buggers here it's not. Just a thought, if you are a Autumn clusterhead like myself, now that winter has
arrived your cycle should be coming to it's end. On becoming
a Monk during a cycle, i've posted an old thread, "Sex" on the
main board.

Hoppy.

I avoid my triggers like the plague when on cycle, foremost being alcohol, sleep cycle disruptions and sustained stress. Avoiding them will reduce the hits but sadly does not eliminate them. As far as when to stop your prevent, I go 2 weeks with ni attacks then I start ramping down. Like everything else, it varies by the individual.

Joe

Hey Jish, you asked:

Quote:

Do a lot of people still experience high levels of pain despite taking large doses of Verapamil along with their abortive of choice well into their cycle?

I take 640mg of verapamil daily, and for the most part it manages the hits and keeps them low. I have had a few screamers nonetheless. I shutter to think what it would be like to not be on verapamil. blessings. lance

Quote:

As far as when to stop your prevent, I go 2 weeks with no attacks then I start ramping down

When you say no attacks - do you mean anywhere on the kip scale? After two months of this cycle, i now kinda have very mild side effects - slight head pressure, blocked nose on one side (now the other side strangely enough), mild shadows but not all of the time.

Quote:

When you say no attacks - do you mean anywhere on the kip scale? After two months of this cycle, i now kinda have very mild side effects - slight head pressure, blocked nose on one side (now the other side strangely enough), mild shadows but not all of the time.

In my cycle, I have lots of periods of head pain / mild discomfort / slight pressure behind the eye -- symptoms that aren't an "attack" but feel more like a condition. Even though these periods pale to the real attack, they are uncomfortable enough to make it difficult to enjoy anything.   Mainly because its impossible not be worried about the mild conditions developing.    Fortunately, 02 often is enough to make them go away.   But not always.   Sometimes even the mild days with CA suck, compared to normal brain days. 

I'm fortunate in that off cycle I don't suffer any headache issues. My prevent is lithium, 1200 mg a day. When I've gone symptom free for 2 weeks, I slowly start weaning off, when I hit 600 mg, if I'm still symptom free, I go off it completely.

Joe