Page 107 - Migraine, the heart and the brain

Cardiac monitoring of high dose verapamil in cluster headache
E-table 2.
Questionaires rst and second Delphi round.
Delphi study: ‘EKG control with Verapamil use for cluster headache’
Currently the best preventive treatment of cluster headache (CH) is verapamil as it reduces attack frequency and the need for attack treatment in the majority of patients. Verapamil is used in doses up to 960 mg/day, which is much more than used for most cardiovascular indications. These doses increase the risk for cardiac toxicity (eg. atrioventricular block and bradycardia).
Because of the risk of cardiac side effects, electrocardiogram (EKG) screening is advised in CH patients using verapamil. Evidence based guidelines for EKG screening, however, are not available.
The aim of this study is to provide a practice guideline for verapamil use in CH based on expert opinion by means of the Delphi method. The Delphi method is a well known method for consensus-building by using a series of questionnaires to collect data from a panel of selected experts. Questionnaires will be sent to 30 selected internationally well know cardiologists, specialized in heart rhythm disorders.
The goal of the study is to achieve consensus on EKG control and dosing regime for CH patients using verapamil. The selected cardiologists will ll in the questionnaires in two or three separate stages.
Questionaire 1:
The questions are about your clinical practice.
Case vignette.
A cluster headache patient without cardiac history, with normal blood pressure and heart rate. No cardiac complaints. No cardiovascular co-medication. There is an indication for preventive treatment with verapamil. The dose is adjusted to the clinical ef cacy.
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Please mark your answers by making the answer bold or underline.
1. An EKG should be made prior to a rst verapamil prescription of 80 mg 3dd1.
Strongly disagree Disagree Neutral Agree Strongly agree
2. Regular EKG checks at set times should be done when on a stable dose of verapamil.
Strongly disagree Disagree Neutral Agree Strongly agree
2a. If so, is this necessary for all doses? (high and low)
Strongly disagree Disagree Neutral Agree Strongly agree
2b. If not necessary for all doses, what is the cut-off dose ( in mg/day) to do regular EKG checks at set times ? day
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3. An EKG should be repeated prior to any dose increase of verapamil. Strongly disagree Disagree Neutral Agree
4. An EKG should be repeated after any dose increase of verapamil. Strongly disagree Disagree Neutral Agree
4a. If so, within how many days after the increase? ....... days after dose increase
Strongly agree Strongly agree
5. Which EKG abnormalities are absolute criteria for discontinuation of verapamil?
6. Which EKG abnormalities are relative criteria for discontinuation of verapamil?
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