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Individualizing Treatment with Verapamil
for Cluster Headache Patients
Joseph N. Blau, Hans O. Engel
Posted: January 2005  
Headache 2004;44:1013-1018

Background:   Verapamil is currently the best available prophylactic drug for patients experiencing cluster headaches (CH). 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 CH by supervising each individual and adjusting the dosage accordingly.

Results:  Seventy consecutive patients, 52 with episodic CH during cluster periods and 19 with chronic CH, were all treated with verapamil as above. Complete relief from headaches was obtained in 49 of 52 with episodic, and 10 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One patient withdrew because verapamil made her too tired, another developed Stevens-Johnson syndrome, and the drug was withdrawn.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.