Abstract
Use of high doses of verapamil in preventive treatment of cluster headache (CH) is limited by cardiac toxicity. We systematically assess the cardiac safety of the very high dose of verapamil (verapamil VHD) in CH patients. Our work was a study performed in two French headache centers (Marseilles–Nice) from 12/2005 to 12/2008. CH patients treated with verapamil VHD (≥720 mg) were considered with a systematic electrocardiogram (EKG) monitoring. Among 200 CH patients, 29 (14.8%) used verapamil VHD (877 ± 227 mg/day). Incidence of EKG changes was 38% (11/29). Seven (24%) patients presented bradycardia considered as nonserious adverse event (NSAE) and four (14%) patients presented arrhythmia (heart block) considered as serious adverse event (SAE). Patients with EKG changes (1,003 ± 295 mg/day) were taking higher doses than those without EKG changes (800 ± 143 mg/day), but doses were similar in patients with SAE (990 ± 316 mg/day) and those with NSAE (1,011 ± 309 mg/day). Around three-quarters (8/11) of patients presented a delayed-onset cardiac adverse event (delay ≥2 years). Our work confirms the need for systematic EKG monitoring in CH patients treated with verapamil. Such cardiac safety assessment must be continued even for patients using VHD without any adverse event for a long time.
Highlights
According to quality criteria developed by the American Academy of Neurology [1], verapamil received a grade C rating in a recent meta-analysis of trials of pharmacotherapy for cluster headache (CH) [2]
Seven (24%) patients presented bradycardia considered as nonserious adverse event (NSAE) and four (14%) patients presented arrhythmia considered as serious adverse event (SAE)
Considering the use of high doses, the cardiac safety of verapamil therapy was studied in one series that included 108 CH patients treated by verapamil with systematic electrocardiogram (EKG)
Summary
According to quality criteria developed by the American Academy of Neurology [1], verapamil received a grade C rating in a recent meta-analysis of trials of pharmacotherapy for cluster headache (CH) [2] In spite of this low evidence level, verapamil is generally considered to be the mainstay of CH preventive therapy as in the European guidelines [3]. The daily dose could be increased up to 720 mg and some CH patients may even need unusual very high daily dose from 720 to 1,200 mg [6] Considering such a clinical practice, the dose of verapamil used for CH is approximately twice the dose required by cardiovascular diseases [7]. We developed a similar approach to assess the cardiac safety of verapamil therapy in CH with a focus on very high daily dose equal or higher than 720 mg/day
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