From reading a bunch of posts, it seems like the correct dosage and timing for Verapamil varies from person to person.

Here's my question, what dosage did folks start on and what kind of indicators did you and your Dr. use to determine when you needed to up your dosage?

Commonly used approach:

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.

I started with 80mg twice a day for two days, increased to 160mg twice a day for two days and now I'm up to 240mg twice a day. I also have to take with food since I'm one of the lucky ones that gets extremely lightheaded and dizzy if I don't.

I can taper back down after 2 weeks with no pain/twinges.

Good luck.

~ Katie

Started on 160 mg per day am now on 360-480mg per day.  Neuro won't up my dose anymore since I am petite in stature.  If things get worse will have to go on Verapamil/Lithium combo.

I started at 360mg, 120 in am, 240 in pm. For me that was ineffective. Over the months following, this was increased in 120mg intervals up to 720mg. This helped bring my major episodes down from 3-4 a day to 1-2 a day. At 720 I was beginning to have very serios bouts of dizziness and passed out completely on a couple of occasions, so now they are reducing, again at 120mg at a time. Apparently my bp was too low. I'm now heading back down to 480mg a day. It seems to be reducing the dizziness. They also put me on a heart monitor but so far, so good. -Chris

Thanks everyone!! I appreciate the technical and the anecdotal stuff, very helpful.

My doc started me a 120 mg, and the extended release (at least I'm assuming that's what "ER" stands for on the label) and I'm just taking 1 dose in the AM.

To be honest, I haven't noticed any relief from the current dosage so I have a call into my doctor about increasing it. However, I have very normal BP so even that dose has made me a little sluggish at times.

I have also noticed a pattern emerging for when I get my hits. I'm getting 4-6 hits a day but the ones I can count on are 7ish am, 9:30ish am, noon (NOW!! ARRGHHH) and 1:30 am, sometimes with a couple in the early evening.

So I'm guessing that, based on some of the responses, the best approach is to take Verapamil a couple of times throughout the day based on timing of hits?

Brew wrote on Nov 5^th, 2010 at 12:39pm:



This makes total sense.

And after you have it under control you can back it off a little. Im seeing my nero next week to talk about Verap for my next cycle(if this last one is done) and I hope he will start high then back off as needed.

Quote:


Initially starting verapamil, prednisone was also given for the first 20 days, tapering from 100mg to nothing, along with Zantec for the stomach and a sleeping aid, I think Ambien. This covered a three week timespan helping stay pf so the verapamil could be taken gradually up to 360mg.  At that point, it might be tapered up or down according to need.

When starting new medications like verap, it's good to gradually introduce them to avoid sudden changes to a system and to see if any adverse effects may coincide.  Everyone can react differently, stay in contact with your doc during the time after the prednisone with feedback to him for an effective level of verap suiting you.

Chris H wrote on Nov 5^th, 2010 at 7:56pm:

...unless your doctor directs you otherwise.

Yan that's great news. I'm sure the doc told you, but start increasing your fruit and fibre intake. One of the side effects of verap is it'll really back up the old digestive tract. A small price to pay for some time off with the beast.

Also a quick reminder to go easy on the energy drinks while on verapamil, the taurine doesn't play well with the verapamil.

Joe

Bob's info is golden, it has all the foot noted medical stuff that doctor's like, as it gives them justifications for the treatments. If possible, organize it and try to get it to your doc a week or so ahead of your appointment. I've found it hard to get a doc to sit and read smething during your appointment, when they're so pressed for time.

Joe