Yes, a conservative, mainline approach to cluster. Good track record on these meds for effectiveness and safety so that he has a deep backgound of experience against which he can check your response to that of many others.

Your contribution: patience!!; don't muck with dosing without his O.K.; read the material you will find here, starting with the buttons (left) and below.
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Cluster headache.
From: Multimedia File Viewing and Clickable Links are available for Registered Members only!!  You need to or (Orphanet Journal of Rare Diseases)
[Easy to read; one of the better overview articles I've seen. Suggest printing the full length article--link, line above--if you are serious about keeping a good medical library on the subject.]

Leroux E, Ducros A.

ABSTRACT: Cluster headache (CH) is a primary headache disease characterized by recurrent short-lasting attacks (15 to 180 minutes) of excruciating unilateral periorbital pain accompanied by ipsilateral autonomic signs (lacrimation, nasal congestion, ptosis, miosis, lid edema, redness of the eye). It affects young adults, predominantly males. Prevalence is estimated at 0.5-1.0/1,000. CH has a circannual and circadian periodicity, attacks being clustered (hence the name) in bouts that can occur during specific months of the year. ALCOHOL IS THE ONLY DIETARY TRIGGER OF CH, STRONG ODORS (MAINLY SOLVENTS AND CIGARETTE SMOKE) AND NAPPING MAY ALSO TRIGGER CH ATTACKS. During bouts, attacks may happen at precise hours, especially during the night. During the attacks, patients tend to be restless. CH may be episodic or chronic, depending on the presence of remission periods. CH IS ASSOCIATED WITH TRIGEMINOVASCULAR ACTIVATION AND NEUROENDOCRINE AND VEGETATIVE DISTURBANCES, HOWEVER, THE PRECISE CAUSATIVE MECHANISMS REMAIN UNKNOWN. Involvement of the hypothalamus (a structure regulating endocrine function and sleep-wake rhythms) has been confirmed, explaining, at least in part, the cyclic aspects of CH. The disease is familial in about 10% of cases. Genetic factors play a role in CH susceptibility, and a causative role has been suggested for the hypocretin receptor gene. Diagnosis is clinical. Differential diagnoses include other primary headache diseases such as migraine, paroxysmal hemicrania and SUNCT syndrome. At present, there is no curative treatment. There are efficient treatments to shorten the painful attacks (acute treatments) and to reduce the number of daily attacks (prophylactic treatments). Acute treatment is based on subcutaneous administration of sumatriptan and high-flow oxygen. Verapamil, lithium, methysergide, prednisone, greater occipital nerve blocks and topiramate may be used for prophylaxis. In refractory cases, deep-brain stimulation of the hypothalamus and greater occipital nerve stimulators have been tried in experimental settings.THE DISEASE COURSE OVER A LIFETIME IS UNPREDICTABLE. Some patients have only one period of attacks, while in others the disease evolves from episodic to chronic form.

PMID: 18651939 [PubMed]

You have a doc who did his homework. Pred and vferap are the most typical and may work for you. They did for me at first. But they do not treat an accute ha attack. That's what the O2 does. Would be curious toknow what lpm he prescribed. anything lest than 12 lpm will not do much for you, and the mask is critical. If doc pescribed less than 12 lpm, ask for more or PM me for other legal options that do not require a script. Spend the $29 and buy an  O2PTIMASK. I did and it was a miracle once I got o2 flow up of 15 lpm. I now use 25 lpm and abort ha's in 15 minutes. IMHO that is the only way O2 works and it is 90% effective at those flows.

Not a fan of occipital nerve blockage. There are much more effective options with less side effects and less risks if you visit clusterbusters.com and read about dosing. Some legal, some not.

O2 and dosing are the most effective short term and long term solutions. But read, read and read again then take action. Develop a plan and execute it. Being in control is crucial to your state of mind. You cannot let provides torment you with their lack of knowledge or willingness to go to the limit to provide you with relief. But again. Get the right O2 set up first then consider your course of action.

Just noticed that you Verap dose is rather low--by our experiental standards. Following is a widelyl used protocol developed by one of the old line headache docs.
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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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This is a "mandatory" disclosure! The problem mentioned is not frequent or so serious that you should avoid the med. But print out both these articles for your doc.

Source: American Academy of Neurology
Date: August 13, 2007
More on: Headache Research, Headaches, Pharmacology, Heart Disease, Diseases and Conditions, Vioxx

Drug For Cluster Headaches May Cause Heart Problems
Science Daily — A drug increasingly used to prevent cluster headaches can cause heart problems, according to a study published in the August 14, 2007, issue of Neurology®, the medical journal of the American Academy of Neurology. Those taking the drug verapamil for cluster headaches should be closely monitored with frequent electrocardiograms (EKGs) for potential development of irregular heartbeats.

Cluster headache is a rare, severe form of headache that is more common in men. The attacks usually occur in cyclical patterns, with frequent attacks over weeks or months generally followed by a period of remission when the headaches stop.

"The benefit of taking verapamil to alleviate the devastating pain of cluster headaches has to be balanced against the risk of causing a heart abnormality that could progress into a more serious problem," said study author Peter Goadsby, MD, PhD, DSc, of the National Hospital for Neurology and Neurosurgery in Queen Square, London, UK, and the University of California, San Francisco and a member of the American Academy of Neurology.

The study involved 108 people with an average age of 44. The participants started taking verapamil and then had an EKG and an increase in the dosage of the drug every two weeks until the headaches were stopped or they started having side effects.

A total of 21 patients, or 19 percent, had problems with the electrical activity of the heart, or irregular heartbeats, while taking the drug. Most of the cases were not considered serious; however, one person required a permanent pacemaker due to the problem. A total of 37 percent of the participants had slower than normal heart rates while on the drug, but the condition was severe enough to warrant stopping the use of the drug in only four cases.

Goadsby noted that 217 people taking the drug were initially supposed to take part in the study, but 42 percent of them did not have the EKGs done to monitor their heart activity. "Many of them said either they or their local services were reluctant to undertake such frequent tests, or they were not aware of the need for the heart monitoring," he said. "Since this drug is relatively new for use in cluster headaches, it's possible that some health care providers are not aware of the problems that can come with its use."

Note: This story has been adapted from a news release issued by American Academy of Neurology.

Hey Putter,

This may be stuff you're already aware of, so forgive me if it's old hat - I just hate to see anyone slipping thru the cracks, not having seen it yet:

Imitrex - These are hopefully injections you've been prescribed, not pills, and they'll make for a solid backup in case you can't get to the O2. This imitrex tip is critical: Multimedia File Viewing and Clickable Links are available for Registered Members only!!  You need to or

Then you'll want to get set up with a non rebreather mask and hi flow regulator for the O2 as outlined in the oxygen info link to the left of this page.

Hey Putter:

I wouldn't be surprised if he ups your verap. at some point
soon. As I came off the pred tapper it was a killer as the pain
intensity increased greatly.  Order the o2 mask on this site,
I did the other day just got it and I have to say it is much
better than any mask you get from the O2 rental
companies.  No outside air leaks in and at $27.50 Plus ship
its worth it.  Nasal works for you that's cool. I hated
spraying that up my nose and it didn't do it for me.
For some exercise helps but if its hot I think its best to keep
heart rate lower than to get it up.  That little guy in your
head really doesn't want you felling good or having fun. 

I hope you find your answer soon.

Also check out high flow regulators on E-Bay. My wife is always on the look out and recently snagged me a 25 LPM for $25 that fits my E-Tanks.

Joe

Hey again, Putter. Just curious what your O2 supplier thought was better than a non-rebreather mask? lance

Leanne, sounds like you have a doc that at least is willing to work with you. For your next visit read and print off the o2 info to your left, a higher flow rate of at least 15 LPM will make a huge difference in the amount of time it takes to abort a CH, and every second counts. Also, the o2ptimask was designed for CH sufferers, you must get one of them.
Verap & Pred. do not break a cycle, they just really help control one. You will find your level of Verap that will help ward off the beast. Also there is a few side effects, such as swelling, mine are my calves, and ekg's are important while on that med.
PF wishes buddy, hang in there, this will take time.
  Barry