Topiramate (Topamax) has received FDA clearance to prevent migraines in adolescents.
A bit of history
Topiramate (Topamax) was originally approved by the FDA in 1996 to prevent seizures. Since then, it was discovered that this class of medicine (anti-epileptics) also has the ability to prevent migraine headaches, although how they do this is not fully understood.
In 2004 the FDA approved topiramate to prevent migraines in adults. Now, it is available for adolescents 12 to 17 years old.
BLACK BOX WARNING
**Topiramate, like any anti-epileptics, can increase the risk of suicide and suicidal thoughts, particularly in adolescents. People taking topiramate, even for migraines, should be seeing a healthcare provider and be monitored for changes in thoughts, mood, or behavior**
A Black Box Warning is a very important piece of information that the FDA requires on any labeling. It is prominently included here due to it's importance.
How do I know if topiramate is right for me?
There are a lot of medicines used to treat and prevent migraines. Many have been used for years and years. Topirimate might be used if others have failed, but it could also be used right away since it has good evidence.
Aside from topiramate, here are some common medicines used to prevent migraines.
- Propranolol is often one of the first medications tried for migraine prophylaxis. Some people can't handle the possible fatigue and exercise intolerance.
- A lot of medicines have been tried for migraine prophylaxis, with not very good results. Still, they may be worth a try in some situations. These include divalproex, verapamil, lisinopril, gabapentin, and candesartan.
- In certain situations, supplements might help, but the evidence is weak and I don't usually recommend them. Some that might help include riboflavin, magnesium, CoQ10, or butterbur.
Here are some of the most common treatments for migraines.
NSAIDS (non-steroidal anti-inflammatory drugs)
- Ibuprofen is a good start since it is available over-the-counter, has few side effects, and treats mild migraines. Use 400-600 mg as soon as a migraine starts.
- Excedrin Migraine combines an NSAID (aspirin) with acetaminophen and caffeine. This combination can be more effective than the ingredients alone. Remember, caffeine may cause anxiety and insomnia.
- There are a lot of choices for triptans, which are really good and stopping migraines. Most people start with sumatriptan (Imitrex), but can also try others. Everybody has a different response to each one, so you have to keep trying until you find the one for you.
What are the benefits of using topiramate?
- It can reduce the number of migraines by 72% (usually 1 to 3 per month fewer).
- Preventing migraines is much more effective than treating migraines.
- Topiramate can also cause weight loss.
- Topiramate has fewer side effects than other, older, medicines used to prevent migraines.
What are the risks of using topiramate?
- The most common side effects are fatigue, nausea, and impaired cognition (cloudy brain).
- It cannot be used in pregnancy (see below).
- It may reduce how well birth control works (see below).
- It can cause serious eye problems. Any changes in sight should be reported right away.
- It increases the risk of suicide and suicidal thoughts (see above).
- It has some rare, but serious, side effects. Anyone using topiramate should be seeing a healthcare professional regularly.
How do I take topiramate?
Since topiramate can take some getting used to, it's best to start with a very low dose and go up slowly. This allows your body to get used to it, and helps reduce side effects. Specifically, it reduces the side effect of reduced cognition, or not being able to think as clearly as usual. If you take too high a dose too quickly, you can feel like your brain isn't as sharp or quick as usual, which can be very dangerous.
The goal dose for best effect is 100 mg daily, taken in two doses, one in the morning and one in the evening.
This table is a good guide for dosing, but you'll want to go up slower if you experience side effects. Some people can't take 100 mg daily without side effects. For them, topiramate probably isn't a good choice.
How to start taking topiramate
Week 4 and on
The birds and the bees
Topiramate has a sort of double whammy when it comes to pregnancy.
First, topiramate at higher doses (200 mg and higher daily) reduce how well estrogen based birth control works (the pill). Some providers may prescribe topiramate at this dose for migraines. Also, lower doses may reduce the effect of birth control in certain situations, as well.
Second, topiramate cannot be taken in pregnancy. Data from studies is clear that if a mother takes topiramate during pregnancy it increases the risk of the child being born with cleft lip or cleft palate. Topiramate is pregnancy category D.
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Another weird side effect of topiramate is that it can cause carbonated drinks to taste funny, or just taste gross. You may not enjoy pop as much as you used to. Sorry!
Have you been on topiramate for a while and decided to stop? Remember to go off slowly just like you started slowly. You need to let your body be used to NOT having it around, too.
Brandon Y is a community pharmacist working in Minnesota with over 10 years of experience in pharmacy. He welcomes comments and questions. Find more great pharmacy tips here.
The information provided on this page is intended for general educational and informational use only. It is not specific, personalized healthcare advice for you. For healthcare advice regarding your particular situation, talk to members of your healthcare team. Contact this hubs author for more information.