Verapamil for vertigo and related disorders.

Timothy C. Hain, MD

Last update: May 1, 2022 •Please read our disclaimer.

The main vertigo disorders where verapamil is used are migraine and Meniere's disease -- two closely related "committee" diagnoses. In other words, these two disorders overlap heavily, are diagnosed using entirely subjective criteria, and could even be often two faces of the same illness.

The usual dose of verapamil is 120 to 240 mg,  SR, once per day. SR means sustained release. This drug is an dihydropyridine L-channel calcium channel blocker, similar to other dihydropyridine drugs like nifedipine, nimodipine and diltiazem.

Verapamil is modestly effective for migraine but it takes about 2 weeks to work, and dose may need to be escalated too requiring more time. According to Davidoff (2002), doses as high as 480 mg/day may be necessary for migraine. Solomon (1989) reported good results in migraine, and both Solomon (1983) as well as Markley (1984) reported good effect in controlled studies. . Verapamil is effective in migraine variants such as hemiplegic migraine (Yu and Horowitz, 2003; Davidoff 2002), perhaps because of the pathophysiology of hemiplegic migraine that can involve the calcium channel receptor. Verapamil is also favored for cluster headache, although the CGRP family of drugs is gaining ground here. Compared to beta-blockers, verapamil is less effective for common migraine (Davidoff, 2002).

Verapamil also may be helpful in Meniere's disease, although this has not yet been documented by a controlled study. Similarly it may be helpful in the overlap between Meniere's and Migraine (Kaya et al, 2019).  A close relative to verapamil, Nimodipine has been reported to be helpful for Meniere's disease (Lassen et al, 1996). Neither of these medications are used commonly in Meniere's. Meniere's disease is plagued by reports of treatments that are initially thought to be helpful, but later inseparable from placebo. This is due the extreme variability and relative infrequency Meniere's, making it easy to be fooled. See this link for more. Meniere's and migraine are close relatives. In fact, about 50% of patients with Meniere's, also have Migraine (Radke et al, 2002; Rassekh et al, 1992). It doesn't work the other way around however. This may be the reason why prevention treatment of Meniere's and migraine, including various diets and medications, overlap extensively. See also: Meniere's diet, Migraine diet.

We favor use of verapamil for migraine particularly in situations where the patient has hypertension, where there is periodicity such as seasonal migraine, cyclic vomiting or benign recurrent vertigo, and in persons with migraine and a large number of white matter lesions for age. This is based on experience, not evidence, but sometimes this is the best one has.

Curiously, both verapamil and the CGRP family of medications are used for cluster headache. The question of whether or not response to one predicts response to the other remains to be asked.

Side effects of verapamil

About 50% of users of verapamil develop constipation. We like to combine verapamil prescriptions with oral magnesium supplements (500 mg/day), as magnesium has some tendency to counteract the constipation and is also a prevention medication for migraine. (Holland, 2012)

Verapamil should not be used in persons with a long cardiac QT interval.

Sometimes verapamil lowers blood pressure but this is generally not a big problem if it is started gradually. About 1% of users develop palpitations (fluttering feeling in chest). Stop taking this drug if you develop palpitations. A few individuals develop swelling of the ankles. Verapamil is safe in patients with asthma, and especially good in patients who also have high blood pressure. The usual starting dose is 120 extended rlease.

Verapamil has no cognitive side effects and no effect on weight. Some studies even reported that calcium channel blockers enhance cognition (Kowalska and Disterhoft, 1994). However, this observation has not stood the test of time.

Other Precautions and Concerns about verapamil

There are several concerns about verapamil that should limit its use. Because of studies suggesting increased mortality from heart disease, verapamil and related drugs in the calcium channel blocker family are not favored in individuals aged 55 and older.   In certain uses, for example to prevent BRV or benign recurrent vertigo, verapamil may still be worth taking the risk.

Verapamil is one of the drugs favored for treatment of cluster headache in pregnancy and lactation (Jurgens et al, 2009).

One study suggested an increased risk of cancer (about 2 fold) in persons taking verapamil in Rotterdam (Biederbeck-Noll et al, 2003). However, the study of Dong et al (1997) included 11,000 patients in all published trials at the time and found "There is no statistically significant increased risk of cancer or deaths with verapamil compared with active controls or placebo." We think the much larger and more geographically diverse study of Dong is more likely to be correct than a smaller study done in a single country. As verapamil is often associated with constipation, and constipation increases the risk of colon cancer, one could speculate that verapamil might increase the risk of colon cancer. However, if one keeps the constipation under control with diet (e.g. magnesium) or appropriate laxatives, this risk should be nonexistent.

Verapamil increases blood levels of simvastatin (Kantola et al, 1998), and possibly other statins as well.  Doses of simvastatin should be reduced to 10mg when verapamil is also prescribed. Statins also increase the bioavailability of verapamil (Choi et al, 2010), and when a statin and verapamil are combined, doses of verapamil should also be decreased.