Roland,
Thanks for the detailed feedback... Ho Lee Key-Rap!!! Sorry you're having such a rough time. You appear to be doing everything right with respect to the anti-inflammatory regimen and you're still getting hammered... at both ends...
Lets start from the top... er... make that the bottom... You're taking the right form of magnesium... just a little too much. Even magnesium citrate at too high a dose can result in osmotic diarrhea... a.k.a. high pressure hydraulic squirts...
You've obviously figured that out as I see where you cut the dose of magnesium citrate in half... If that doesn't solidify things a bit, cut it in half again...
We've found that viral infections like the flu and colds suck up vitamin D3 like it was going out of style... This slows the process of building serum 25(OH)D reserves and has kept a few of us from going pain free on the anti-inflammatory regimen.
There are several studies that found our immune system's T-Cells suck up large amounts of 25(OH)D in response to viral infections, trauma, and major surgery as indicated by a sharp drop in serum 25(OH)D concentrations...
The best rule of thumb if you've caught a flu bug or a bad cold is double the present dose of vitamin D3 until the flu or cold symptoms clear. A 50,000 IU loading dose of vitamin D3 once a week wouldn't hurt as long as the viral symptoms are present..
I've been pain free of my CH since Oct 2010 when I started the anti-inflammatory regimen... with three exceptions. All three times I intentionally stopped taking the entire anti-inflammatory regimen as a burn down test of my 25(OH)D reserves... In all three cases, the beast came a knocking after an average of 8 days without vitamin D3 and the cofactors.
Two weeks ago while on travel, I caught a very nasty cold, my first since Oct of 2010. All was going well at my usual maintenance dose of 10,000 IU/day vitamin D3. The cold symptoms appeared less sever and the sequence of cold symptoms were progressing faster than usual... until I missed my daily dose of the anti-inflammatory regimen... Wham-O... the beast came racing back and the cold turned ugly.
I took a 50,000 IU vitamin D3 loading dose and bumped my daily intake of vitamin D3 to 25,000 IU/day a week... The beast beat feet and the cold symptoms subsided in less than a week.
On the topic of the "normal" reference range for the 25(OH)D lab test... One of the largest medical diagnostic firms in the world, Quest Diagnostics, uses serum concentrations of 30 ng/mL (75 nmol/L) to 100 ng/mL, (250 nmol/L) as the optimal therapeutic reference range for 25(OH)D.
The consensus of most medical experts in vitamin D3 therapy concludes a serum concentration of 25(OH)D3 of 21 to 29 ng/mL (52.5 to 72.5 nmol/L) is considered a vitamin D3 insufficiency and ≤20 ng/mL, (50 nmol/L) is a vitamin D3 deficiency... with respect to rickets, osteoporosis and osteomalacia... not cluster headache.
These same experts say 60 ng/mL, (150 nmol/L) as an optimum therapeutic level of 25(OH)D to maintain.
The results of the online survey of CH'ers using the anti-inflammatory regimen and who experienced a pain free response averaged a 25(OH)D serum concentration of 81.4 ng/mL, (203.5 nmol/L).
I'm not a doctor or a licensed nutritionist... That said, here's where a little understanding of how these "normal" reference ranges for 25(OH)D3 are derived comes in handy.
Most reference ranges are derived from the National Health and Nutrition Examination Survey (NHANES) data base of lab tests and survey results collected and reported to CDC.
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When these test and survey results are plotted out, the medical bean counters and statisticians get a bell shaped, gaussian "Normal" distribution curve as shown in the following graphic.
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I've overlaid the latest NHANES data for 25(OH)D in red print. As you can see, the lower 5% of the 8306 participants surveyed had a 25(OH)D serum concentration less than 8.8 ng/mL, (22 nmol/L). The 50th percentile and mean 25(OH)D serum concentration is 23.9 ng/mL (59.75 nmol/L) and 95% of the 8306 participants surveyed had a 25(OH)D serum concentration ≤ 38.5 ng/mL, (96.25 nmol/L)
Had we plotted out the same figures for paleo man or his modern day counterpart, a healthy Southern California Lifeguard, the curve would be off the scale to the right. The mean serum 25(OH)D concentration of a SoCal Lifeguard is around 100 ng/mL, (250 nmol/L).
The unfortunate part of all this normal reference range stuff is too many physicians take the levels published by the Food and Nutrition Board at the Institute of Medicine (read big Government) as gospel... and their recommended daily vitamin D3 intake is 400 IU/day. Moreover, too many of these physicians are perfectly satisfied if your 25(OH)D serum concentration is 31 ng/mL, (77.5 nmol/L).
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The following chart overlaid with color bands represents before and after 25(OH)D results after starting the anti-inflammatory regimen:
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So what does all this mean to you? The bottom line is simple... You need to be your own best advocate when it comes to controlling your cluster headaches.
That doesn't mean you blow off your doctors recommended treatments... It does mean you can and should question them. Above all, don't be afraid to ask about side effects... Educating them helps and most are receptive to new CH treatments if you show them the supporting data.
For example, your 25(OH)D serum concentration at 67 nmol/L, (27 ng/mL) is still insufficient according to the experts in vitamin D3 therapy... and well below the 60 to 110 ng/mL, (150 to 275 nmol/L) where 81% of the CH'ers who start this regimen experience a significant reduction in the frequency, severity and duration of their CH... or go pain free.
The best course of action... I would stick with the anti-inflammatory regimen with the following modifications. Cut the Omega 3 Fish Oil back to 1000 mg/day, keep adjusting the magnesium citrate to keep things firm and stick with your present vitamin D3 dosing schedule of 20,000 IU/day plus the weekly 50,000 IU loading dose. When your cold symptoms clear, you'll start building 25(OH)D reserves a lot faster.
There's nothing wrong in adding verapamil as needed. Just take it in the morning and the rest of the anti-inflammatory regimen in the evening with the largest meal to improve absorption.
Take care, hang in there and please keep us posted.
V/R, Batch