Verapamil
Neurology. 2007 Aug 14;69(7):668-75.
Electrocardiographic abnormalities in patients with cluster headache on
verapamil therapy.
Cohen AS, Matharu MS, Goadsby PJ.
Headache Group, Institute of Neurology, The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK.
BACKGROUND: High dose verapamil is an increasingly common preventive treatment in cluster headache (CH). Side effects include atrioventricular block and bradycardia, although their incidence in this population is not clear.
METHOD: This audit study assessed the incidence of arrhythmias on high dose verapamil in patients with cluster headache.
RESULTS: Of three hundred sixty-nine patients with cluster headache, 217 outpatients (175 men) received verapamil, starting at 240 mg daily and increasing by 80 mg every 2 weeks with a check electrocardiogram (EKG), until the CH was suppressed, side effects intervened, or to a maximum daily dose of 960 mg. One patient had 1,200 mg/day. Eighty-nine patients (41%) had no EKGs. One hundred eight had EKGs in the hospital notes, and a further 20 had EKGs done elsewhere. Twenty-one of 108 patients (19%) had arrhythmias. Thirteen (12%) had first-degree heart block (PR > 0.2 s), at 240 to 960 mg/day, with one requiring a permanent pacemaker. Four patients had junctional rhythm, and one had second-degree heart block. Four patients had right bundle branch block. There was bradycardia (HR < 60 bpm) in 39 patients (36%), but verapamil was stopped in only 4 patients. In eight patients the PR interval was lengthened, but not to >0.2 s. The incidence of arrhythmias on verapamil in this patient group is 19%, and bradycardia 36%.
CONCLUSION: We therefore strongly recommend EKG monitoring in all patients with cluster headache on verapamil, to observe for the potential development of atrioventricular block and symptomatic bradycardia.
PMID: 17698788
Individualizing treatment with verapamil for cluster
headache patients.
Blau JN, Engel HO.
City of London Migraine Clinic, London, UK.
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.
PMID: 15546265
J Neurol Neurosurg Psychiatry. 2005 Jan;76(1):124-7.
Verapamil induced gingival enlargement in cluster headache.
Matharu MS, van Vliet JA, Ferrari MD, Goadsby PJ.
Headache Group, Institute of Neurology, Queen Square, London WC1N 3BG, UK.
peterg@ion.ucl.ac.uk
Verapamil is an effective prophylactic treatment for cluster headaches and,
therefore, is widely used. This report describes four patients with cluster
headache who developed gingival enlargement after initiating treatment with
verapamil. In two patients, it was possible to control this side effect
adequately by optimising oral hygiene and dental plaque control. In the other
two patients, lowering of the verapamil dose, in addition to optimal oral
hygiene and dental plaque control, was necessary; in one patient verapamil had
to be stopped completely to reverse the gingival enlargement. Doctors treating
cluster headache with verapamil need to be aware of this side effect, especially
as it may be preventable with good dental hygiene and dental plaque control, is
reversible with reduction or cessation of verapamil, and can lead to dental
loss.
Double blind comparison of lithium and verapamil in cluster
headache prophylaxis.
Bussone G, Leone M, Peccarisi C, Micieli G, Granella F, Magri M, Manzoni GC,
Nappi G.
Headache Centre, C. Besta Neurological Institute of Milan, Italy.
Chronic Cluster Headache (CCH) treatment is troublesome; since there are no
pain-free periods, it must be continuous. The most effective CCH prophylactic
drug today is lithium carbonate but long-term use of this drug is limited by the
possibility of side effects. Recently, calcium antagonists have been
successfully employed to prevent migraine, and preliminary studies also indicate
that verapamil in particular is an efficacious treatment for CCH. We have
conducted a multicenter trial employing a double-dummy, double blind, cross-over
protocol, comparing verapamil with the established efficacy of lithium
carbonate, in preventing CCH attacks. Both lithium carbonate and verapamil were
effective in preventing CCH but verapamil caused fewer side effects and had a
shorter latency period. We did not observe any correlation between plasma levels
of the two drugs and their clinical efficacy. Both the drugs tested here may
exert their effect by restoring a normal inhibitory tone to the pain modulating
pathways from the trigemino-vascular system, a circuit putatively implicated in
CCH.
PMID: 2205598
Headache. 1989 Mar;29(3):167-8.
Prophylactic treatment of cluster headache with Verapamil.
Gabai IJ, Spierings EL
An open study of Verapamil in cluster headache is reported. Forty-eight patients participated in the study of whom 33 (= 69%) improved more than 75%. No significant differences in response were observed between episodic and chronic cluster headache.
PMID: 2708046
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