By Marcello Cherchi, MD PhD
For patients
Verapamil is a heart medication. It is sometimes also used to treat Ménière’s disease and several other diseases that can cause disequilibrium.
For clinicians
Practical summary
Verapamil was originally developed for the treatment of several cardiovascular disorders. It has several off-label uses in otoneurology, including prophylactic management of Ménière’s disease, migraine, cyclic vomiting syndrome and perhaps visual snow syndrome. The most commonly encountered adverse effects include constipation and hypotension. Verapamil may be relatively contraindicated in some cardiovascular disorders.
Introduction
Verapamil was released in 1962 (Singh et al. 1978) for the treatment of several cardiovascular conditions.
Pharmacology
Verapamil is a synthetic papaverine derivative calcium channel blocker (Solomon 1989) for voltage-gated T‑ and L‑calcium channels (Godfraind 2017). It was originally designed for treating certain cardiovascular conditions. Its ability to prolong atrioventricular conduction made it useful for treating reentrant supraventricular arrhythmias. Verapamil also inhibits activity of smooth muscle in blood vessels, resulting in vasodilation, which has made it useful as an anti-hypertensive agent.
Adverse effects
Verapamil is generally well-tolerated. At higher doses it can lower blood pressure (to the point of provoking lightheadedness) and cause constipation.
Cautions and contraindications
Verapamil is relatively contraindicated in patients with a history of myocardial infarction, certain cardiac arrhythmias and hypotension.
Relevance in otoneurology
In earlier studies verapamil appeared to show promise as a migraine prophylactic (Solomon 1989), but a subsequent evidence-based guideline (Holland et al. 2012) concluded that there was insufficient evidence for its efficacy.
Verapamil has not been studied in randomized controlled trials as a treatment for Ménière’s disease. Some investigators speculate that insofar as verapamil appears to be efficacious for Ménière’s disease, it is also possible that it is instead treating migraine associated vertigo, which can mimic the vertiginous component of Ménière’s disease.
Other applications for verapamil in otoneurology include cyclic vomiting syndrome, some cerebellar disorders and perhaps visual snow syndrome.
Verapamil can also be considered for vestibular patients with comorbid cluster headache.
Other notes
We generally prescribe verapamil at an initial dose of 80 – 120 mg per day, and rarely escalate to 240 mg per day.
References
Godfraind T (2017) Discovery and Development of Calcium Channel Blockers. Front Pharmacol 8: 286. doi: 10.3389/fphar.2017.00286
Holland S, Silberstein SD, Freitag F, Dodick DW, Argoff C, Ashman E, Quality Standards Subcommittee of the American Academy of N, the American Headache S (2012) Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 78: 1346-53. doi: 10.1212/WNL.0b013e3182535d0c
Singh BN, Ellrodt G, Peter CT (1978) Verapamil: a review of its pharmacological properties and therapeutic use. Drugs 15: 169-97. doi: 10.2165/00003495-197815030-00001
Solomon GD (1989) Verapamil in migraine prophylaxis–a five-year review. Headache 29: 425-7. doi: 10.1111/j.1526-4610.1989.hed2907425.x
