Page 105 - Migraine, the heart and the brain

Cardiac monitoring of high dose verapamil in cluster headache
release14 or not speci ed.10 Most cluster headache guidelines do not specify the formulation. The panel did not favor any particular formulation.
The highest recommended daily doses of verapamil ranged from 240mg to 960 mg (mean 550 mg) which is consistent with the doses used in the ef cacy studies (on average 354-360 mg/day in episodic cluster headache9,13 and 574 mg/day in chronic cluster9). In review articles and guidelines, doses up to 1200 mg are sometimes advised.11,13
Recommendations
Based on the results of our study, we recommend performing a pretreatment EKG before initiating verapamil therapy but this is not necessary in patients who did not experience adverse events during previous treatment with verapamil. No consensus- based recommendations on EKG monitoring during verapamil treatment and around dose increases can be given although, based on the literature EKG prior and after every dose increase would be a logical recommendation. It goes without saying that individual patient characteristics always have to be taken into account. Future studies should compare different EKG regimes prospectively.
Clinical implications: 6 Experts agreed on performing pretreatment EKG when prescribing Verapamil
Pretreatment EKG was deemed not necessary for patients who did not have
cardiac adverse events during a previous period of cluster headache attacks
treated with Verapamil.
E-Table 1. Panellists
Mehmet K. Aktas, MD, FHRS
University of Rochester Medical Center, Rochester, New York, United States
Carlo De Asmundis, MD, PhD, FHRS
Vrije Universiteit Brussel,UZ Brussel - Heart Rhythm Management Centre, Brussels, Belgium
Nitish Nadhwar, MBBS, FHRS, CCDS
Section of Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Francisco, United States
David G. Benditt, MD, FHRS, CCDS
University of Minnesota, Minneapolis, MN, United States
Deepak Bhakta, MD, FHRS, CCDS
Division of Cardiology, Department of Medicine, Krannert Institute of Cardiology Department of Biostatistics, Indiana University, Indianapolis, Indiana, USA.
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