Welcome in Mike, sorry to hear beasty is back. I have constant ringing in my ears but I factor most of that into my prior career, too much shooting without hearing proteection. Although I suppose it's possible CH plays a role too. Print this out for your neuro, it's from a source he will recognize, your verap dose is very low. What's the dose on the prednisone?

A widely used protocol. Your doc will recognize the source and author:

Headache. 2004 Nov;44(10):1013-8.   

Individualizing treatment with verapamil for cluster headache patients.
Blau JN, Engel HO.


    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. (Headache 2004;44:1013-1018).

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SLOW-RELEASE VERAPAMIL

Dr. Sheftell applauded the protocol for verapamil used by Dr. Goadsby and colleagues, which entailed use of short-acting verapamil in increments of 80 mg. “This method was suggested by Lee Kudrow, MD, 20 years ago as an alternative to slow-release verapamil,” Dr. Sheftell noted.

“I would agree with using short-acting verapamil, rather than the sustained-release formulation, in cluster headache,” he said. “I prefer the short-acting formulation with regard to ability to titrate more accurately and safely. My clinical experience anecdotally demonstrates improved responses when patients are switched from sustained-release verapamil to short-acting verapamil.”

Dr. Goadsby agreed that his clinical experience was similar. “There are no well-controlled, placebo-controlled, dose-ranging studies to direct treatment. This is one of those areas where clinicians who treat cluster headache have to combine what modicum of evidence is available with their own clinical experience,” Dr. Sheftell commented

Joe

Your taper us right in line with what most do, some start at 100 mg but for a first go around sounds like he knows his stuff. I'm lucky, at dosing as low as 30 mg I'm headache free. Like with everything else about CH, what works for some doesn't work for others.

Do read the oxygen link as it must be used correctly or it won't work. The critical points:

A high flow rate, minimum is 15 LPM, 25-40 works faster.

A Non Re Breather Mask. Re breather masks and nasal canulas are recipes for failure.

Get on it as soon as you feel the tension in your scalp. A delay of even a few minutes can extend my abort times.

The key is getting 100% oxygen to your lungs, at a rate to support hyperventilation. That's why it's critical you get the high flow rate, and the Non Re Breather Mask. My aborts run about 6-8 minutes, that's from onset to pain free. Hoping it works as well for you.

As to the verapamil, most find it takes 10-14 days to see any beneficial effect, that's why he put you on the transitional med, the prednisone, while he watches how your body processes the verapamil. DO NOT  increase or decrease verapamil dosing on your own, it's a high horse power med that requires a doctors monitoring. I assume from what you said you wouldn't, but I didn't want to make it sound like we play fast and loose with dosing.

Lastly, do check out the Batch Regimen, the post under medications is called "123 pain free days and I think I know why." Simple vitamin/anti-inflammatory regimen that's helping way too many people to ignore.

JOe