Topiramate Migraine

Headaches and migraines are common conditions. However, a migraine is more than a headache as it’s more severe, usually lasting up to 72 hours. Throbbing pain on one side of the head is one of the characteristics of a migraine attack. It comes with other symptoms, like nausea and light sensitivity.

Luckily, drugs can prevent migraines, making them less severe and frequent. 

Topiramate is just one of these medications. In this article, we’ll discuss topiramate’s dosage, side effects, and what happens in the event of an overdose. First, let’s cover what a migraine is, the symptoms, and the diagnosis. 

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What is a migraine?

A migraine is a disabling neurological disease characterized by throbbing pain on one side of the head. It has different signs and symptoms, and the treatment methods differ from other headache disorders. 

There are an estimated 39 million people in the US living with migraine. The number is probably higher, considering only a few Americans get a diagnosis and treatment. 

Migraine medication stops symptoms and prevents future attacks. It has two broad categories:

  • Pain relief: You take these drugs during a migraine attack to stop the syndrome. They are also known as abortive or acute treatment.

  • Preventive: These drugs reduce the frequency or severity of migraines. You take these regularly, often daily. They’re also known as prophylactics. 

The choice of migraine medication depends on: 

  • The severity and frequency of the headache

  • If the headaches come with nausea and vomiting

  • Your other medical conditions

  • The resultant level of disability

Signs and symptoms of migraine

Many people can't tell the difference between a headache and a migraine. Symptoms of migraines vary widely from one person to another. These symptoms indicate a migraine:

  • Moderate to severe pain

  • Throbbing, pounding, or pulsating sensation in the head

  • There's pain on one or both sides of the head

  • Nausea or vomiting

  • Pain increases with physical activity

  • Sensitivity to light and sound

  • Head pain that lasts from hours to several days

  • Head pain that affects your quality of life, causing you to miss school, work, or other routine activities.

Some people experience migraine attacks that affect their senses, including sound and sight. This type of migraine attack is known as migraine with aura. Visual auras are the most common, and you might experience flashes, zig-zag patterns, and blind spots. Usually, aura precedes a migraine attack and resolves within an hour. 

According to the IHS Classification ICHD-3,¹ there are six subtypes of migraines:

  1. Migraine without aura

  2. Migraine with aura

  3. Chronic migraine

  4. Complications of migraine

  5. Probable migraines

  6. Episodic syndromes that may be associated with migraine

Migraine diagnosis

Doctors don't always perform tests (blood tests, CT scan, MRI, or ultrasound) when diagnosing migraine unless they discover red flags. Your doctor can only tell that you have a migraine through consultation. 

They will ask you several questions to understand the specifics of your headache. The following are questions they may ask you:

  • When did you start experiencing head pain?

  • How often do you have these attacks in a week/month?

  • How can you describe the head pain? Is it mild, moderate, or severe?

  • Are there other symptoms accompanying the pain? This may include vomiting, nausea, or sensitivity to light or noise.

  • How long do the head pains last?

  • Do the attacks stop you or impact how well you perform your daily activities? 

  • Have you ever had an MRI or CT scan?

  • Do you know if a close relative has reported bad head pain?

Treatment options for migraine

There are two approaches to migraine treatment:

Acute treatment 

This treatment approach involves taking medications during a migraine attack to stop it from progressing. Medicine may include over-the-counter (OTC) drugs and prescription medication (such as sumatriptan and rizatriptan). These drugs are available as tablets, shots, or nasal sprays, and they block pain routes in the brain

Preventive treatment 

Preventive therapy reduces the severity, frequency, and length of migraine attacks before they occur. The treatment might be medical (drugs and clinical procedures) and non-medical, such as lifestyle changes, behavioral therapy, trigger avoidance, and physiotherapy. 

Scientists have discovered that cognitive behavioral therapy (CBT)² can significantly reduce the frequency and severity of migraine symptoms, especially if you have a mental health disorder.  

The American Academy of Family Physicians (AAFP)³ found that approximately 38% of people experiencing episodic migraines could benefit from preventive treatment, but less than 13% take prophylactic drugs. For prevention, your doctor will prescribe an effective first-line medication. These include:

  • Divalproex

  • Propranolol

  • Timolol

  • Metoprolol

  • Topiramate (Topamax)

Although we've listed a variety of preventive medications for migraine, this article focuses on topiramate (Topamax). 

What is topiramate (Topamax) for migraines?

Topiramate belongs to a class of drugs known as anticonvulsants, typically manufactured for epilepsy treatment. They are also called antiepileptic drugs. While topiramate treats seizures in people with epilepsy, the Food and Drug Administration (FDA) approved it⁴ for preventing migraine attacks in adults. 

Scientists haven't yet determined how it prevents a migraine. However, they discovered that it inhibits the neuronal hyperexcitability associated with migraine development.⁵ In other words, it calms hyperactive nerve cells in the brain that cause severe head pains. 

The tablets are available in 25, 50, 100, or 200mg, while the sprinkle capsules come in 15 and 25mg. The drug is available as immediate and extended-release formulations, both as original brand medication or in its generic form. The latter is usually more affordable and typically preferred by insurance providers. 

How to use topiramate

Always read the medication guide that comes with the drug packaging before taking the drug. Ask your doctor or pharmacist any questions you have about the medication.

You can take topiramate with or without food as prescribed by your doctor, usually twice a day. You should drink plenty of water after taking Topamax to prevent kidney stones unless your physician advises otherwise. 

When taking a Topamax pill, swallow it whole. Chewing leaves a bitter taste, and it can affect how your body absorbs the drug. 

If you have trouble swallowing a Topamax Sprinkle Capsule whole, you can take it with soft food. Open the capsule and mix the medicine with a spoonful of applesauce or soft food. Swallow the food and medicine mixture straightaway without chewing. Never save the mixture for later use; always create a fresh batch for each dose. 

Topiramate recommended dosage

Topiramate dosage depends on several factors, such as the severity of your attacks and your response to treatment. Weight is also a factor, especially for children's prescriptions. Your doctor will increase your dosage gradually to reduce the risks of side effects. 

Doctors can prescribe up to 100mg daily to patients above 12 years, to take as two divided doses. The recommended starting dosage is 25mg, once every evening. 

Your doctor can increase your dose as follows:

After a week: 25mg in the morning and 25mg in the evening. 

After two weeks: 25mg in the morning and 50mg in the evening. 

After three weeks: 50 mg in the morning and 50mg in the evening. 

How long until Topamax starts working?

You won’t notice a reduction in your migraine severity and duration immediately after taking your initial dose. It might take several weeks to notice a difference, and it takes up to three months for the drug to become fully effective. Taking the medication exactly as your doctor prescribes is vital to feel its effects.

Don't stop taking Topamax because you're feeling better. Wait until your doctor recommends you stop. As some conditions worsen if you suddenly stop taking the drug, your doctor will gradually decrease the dosage as your health improves.

Keep them updated on your symptoms and any side effects while taking Topamax. 

Common side effects of topiramate (Topamax)

As with other drugs, some patients can't tolerate topiramate. The following are the most common side effects of the medication:

  • Drowsiness, dizziness, and fatigue

  • Weight loss

  • Heartburn

  • Nausea, stomach ache, and diarrhea

  • Tingling sensation in the hands and feet

  • Taste changes

  • Memory loss

  • Decreased skin sensitivity

  • Speech problems

  • Nervousness

  • Trouble sleeping

  • Nose and throat infections

  • Fever

Doctors only prescribe medication when they've determined that the benefits outweigh the risk of side effects. Most people taking prescription Topamax don't have any severe side effects. 

Nonetheless, the medication can cause serious side effects that require urgent medical attention. If you have the following side effects, contact your doctor immediately:

  • Kidney stones: Symptoms include severe back, abdominal, side, or groin pain; painful, bloody, or pink urine; and fever

  • Sight problems, including loss of vision (usually within the first month of treatment)

  • Fast, slow, or irregular heartbeat

  • Decreased sweating can result in increased body temperature

  • Rapid breathing

  • Metabolic acidosis: Symptoms include nausea, vomiting, and fatigue

  • Suicidal thoughts 

Some people develop allergic reactions that range from mild to severe. Symptoms of allergic reaction to Topamax include:

  • Itchiness

  • Skin rash

  • Flushing

  • Swelling in the throat, mouth, or tongue

  • Labored breathing

  • Chest pain

If you have symptoms of an allergic reaction, seek immediate medical attention and stop taking topiramate.

On rare occasions, topiramate can cause serious drug-interaction side effects. Tell your doctor about all medications and supplements you’re currently taking to reduce the risk of any interactions. Topiramate is associated with hypothermia in patients taking valproic acid.

Contact your doctor if you experience decreased alertness, unexplained fatigue, and vomiting.

To avoid putting others at risk, don't share your medication. Your doctor will want to monitor any side effects. Topiramate is associated with adverse side effects, including eye problems and hyperchloremic metabolic acidosis, 

Research shows the effectiveness of topiramate

Topiramate is highly effective in reducing migraine frequency in people suffering from chronic migraine. In one study,⁶ people with chronic migraines took 75mg of topiramate daily for 30 days. After 30 days, they registered a significant reduction in headache frequency and lowered Migraine Disability Assessment (MIDAS) scores. 

Another study⁷ with 1,500 participants found that monthly migraine frequency in people treated with 100mg of topiramate per day decreased by 46.5%. 

A study⁸ with 483 participants found topiramate to be a highly effective migraine treatment. People who took 100 and 200mg of topiramate per day reported significantly decreasing migraine days, severity, and duration. The group also reported a reduced need for rescue medication to deal with their migraine.   

Scientists haven't studied the effectiveness of topiramate against other antiepileptic drugs. Still, a study⁹ using propranolol as an active control showed that topiramate and propranolol had the same efficacy. They reduced migraine attacks by 1.6 headaches every month. 

How to maximize your topiramate medication

Although research shows that topiramate can reduce migraine severity, frequency, and duration, some practices can help you get the most from your treatment.

See your doctor

Keep your appointments so that your doctor can monitor your progress. You'll also need to have eye tests and occasional weight checks. 

Take the drug as prescribed

Take topiramate according to your doctor's prescription. Suddenly stopping it can cause issues, and your physician may gradually want to reduce your dosage when necessary.

Take painkillers where needed

Topiramate prevents migraines, but it doesn't stop the condition completely. You can treat the pain by taking painkillers or a triptan if a migraine attack occurs.

Medication-induced head pain? Speak to your doctor

Some people who experience migraine suffer from medication-induced headaches due to extended or frequent painkiller use. If you take pain relievers for more than two days a week, you could be at risk of migraine attacks. Speak to your doctor if you think your head pain is medication-induced. 

Learn your migraine triggers

Several things can trigger migraine, including: 

  • Foods such as red wine, chocolate, and cheese

  • Bright light

  • Skipping meals

  • Stress and anxiety

If you're unsure of what causes your severe head pain, keep a migraine diary. Document when and where each migraine attack occurs, what you were doing, and the food you ate. You'll notice a pattern after some time and know what triggers to avoid.

Find the right birth control for you

Avoid getting pregnant during topiramate treatment as it increases the baby’s risk of oral clefts. Ask your doctor about the best contraceptives for you and your partner. 

Always check if medications interact

If you’re buying an over-the-counter medicine, always check with the pharmacist to ensure it’s safe to take with Topamax. 

Precautions when taking topiramate

Some medicines aren't suitable for people with certain health conditions. Other situations require you to administer the drug with extra care. Therefore, consult your doctor before taking topiramate in the following circumstances:

  • If you have any allergies: Topamax might contain inactive ingredients that could cause allergic reactions and other serious side effects.

  • If you're pregnant or a lactating mother, there is an increased risk of side effects when taking topiramate. You should only take it when your doctor agrees the benefits outweigh the risks. In breastfeeding mothers, the medication passes into breast milk, which may result in adverse health effects for the baby.

  • If you have a rare inherited blood disorder called porphyria¹⁰ 

  • If you're taking any other medication (OTC drugs, herbal medicine, or supplements) 

  • If you have any kidney problems (kidney stones) or liver problems

Topiramate can make you dizzy. It's not advisable to drink alcohol or use marijuana when taking topiramate. They can worsen the side effects and impair your judgment. Don't drive or operate machinery or participate in any activity requiring alertness.

Additionally, the drug can reduce sweating and increase body temperature, so you could easily develop heat stroke. Avoid any strenuous activity or physical exercise that overheats you. If you get too hot, find a cool place and rest until your body cools down.

If you have a fever that doesn't go away, contact your doctor immediately. 

Children are especially susceptible to the side effects of Topamax. It may weaken a child's bones, slow their growth rate, and reduce sweating. 

This drug may cause dizziness among older adults, increasing their risk of falling.  

Drug interactions

A drug interaction is a reaction or change in a drug's effect on the body when you take it with another drug. That interaction can increase or decrease the action of either or both drugs or cause serious side effects. These effects vary widely, and this article doesn't provide a complete list of all possible outcomes. 

Keep a note of all drugs or complementary medicine you use and share that information with your doctor or pharmacist. 

Topamax is unsuitable for pregnant women because it’s associated with an increased risk of congenital disabilities.¹¹ Babies born to those who took Topamax during pregnancy are likely to be small for their gestational age and have cleft lip or palate. 

Unfortunately, Topamax also increases the likelihood of getting pregnant by reducing the efficacy of estrogen-based birth control drugs. With the help of a medical professional, you can get guidance on other birth control options that work with topiramate. 

Also, inform your doctor if you have new spotting or breakthrough bleeding because it might indicate that your birth control products aren't working as expected. 

If you use one or more of the following drugs, tell your pharmacist or doctor:

  • Drugs that cause drowsiness, such as alcohol and marijuana

  • Antihistamines, such as cetirizine¹² and diphenhydramine

  • Drugs for sleep and anxiety treatment, such as diazepam, alprazolam, and zolpidem

  • Muscle relaxants

  • Opioid pain relievers, such as codeine

Overdose

An overdose can result in severe symptoms, such as breathing difficulties, loss of consciousness, and severe drowsiness. If someone has overdosed, call 911 immediately. Alternatively, you can contact US Poison Control at 1-800-222-1222. 

Missed dose

It's not uncommon for people to forget to take their medication. If you miss a dose, take it once you remember. If the subsequent dose is within six hours, skip the missed dose, but remember to take your next dose. Don’t double dose to catch up with your schedule. 

Call your doctor for guidance if you miss more than one dose. 

How to store topiramate

Store topiramate in an airtight container at room temperature, away from direct light and moisture. Keep topiramate away from children and pets.

When discarding topiramate, don't flush it down the toilet or pour it into the drain unless advised otherwise. Dispose of it properly to avoid risks to people, animals, and the environment. Consult your doctor or pharmacist on how to throw away expired or unused medication.

Many pharmacies operate take-back programs for safe drug disposal. 

The lowdown

Migraines are a common condition causing symptoms from headaches to nausea. You don’t have to suffer in silence as there are many treatments available, including medication like topiramate.

While these drugs can be helpful for some people, others can’t tolerate the side effects, so it’s best to speak to your doctor if you have concerns.

Medication is only part of your migraine treatment plan, though. You’ll also need to identify your triggers, have regular reviews with your doctor, and determine if your headaches are medication-induced. You can get your migraines under control by taking a broader look at your symptoms and controlling some aspects, like your triggers. 

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Visit us online to find a clinical trial near you. 

Have you considered clinical trials for Migraine?

We make it easy for you to participate in a clinical trial for Migraine, and get access to the latest treatments not yet widely available - and be a part of finding a cure.

Joining community groups and exercise programs for my condition made me feel empowered – but I want to be part of finding a cure.
Peter, 64

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Last updated: Sep 2022

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