Topamax (topiramate) is an anticonvulsant agent that has significant efficacy for the management of headache.  Information on the basic pharmacology and prescribing information in epilepsy may be found on the Ortho-McNeil website: http://www.topamax.com/ . I have found Topamax useful in the management of pain and as an agent that promotes significant weight loss .  It is used increasingly by psychiatrists for the management of mood disorders.  Topamax has been approved by the FDA approved for Headache and has the added benefit of weight loss. One of the keys is to increase the dose slowly as described below. The combination of Topamax and BOTOX seems particularly useful.

I will describe how I use Topamax in the management of headaches assuming that a need is determined for a preventive agent ( see section on Preventive Therapy elsewhere on this Website ).

Dose: The dose in increased quite gradually, just 25 mg per week, adding first at night and then  in the morning.  When a dose of two 25 mg pills, AM and PM is reached, I usually keep a patient at that level for two to three weeks to determine efficacy of the 100 mg/d dose.  I have often gradually increased patients to 200 or 400 mg/d depending on tolerance and effectiveness and have one patients doing very well on 1000 mg/d that she tolerates amazingly well with no headaches and no side effects.

Side Effects: Patients are told at the outset that about 5%-15% of patients experience cognitive dysfunction in the form of mild confusion or word finding difficulty.  The effect is often notable even at the lowest starting dose: 25 mg. at bedtime.  Other side effects including dyesthesia ( burning ) of the fingers or toes, but this usually disappears or becomes less bothersome.  The appetite suppression seems to start almost immediately. Other potential side effects include a sudden increase in intraocular pressure with blurred vision and eye pain.  Patients should be warned to immediately discontinue upon developing ocular pain and consult an eye physician. This is apparently due to an idiosyncratic swelling of the ciliary body and is usually reversible upon stopping the drug.  This side effect is rare occurring in about 8/1,000,000 persons and occurring in the first two weeks of treatment according to an abstract at the Academy of Neurology meetings in 2002.  Rarely also there is an association with an increased incidence of kidney stones.

Weight Loss requires a special comment.  When I was treating patients I would encourage them to weigh only a single time each week (Thursday AM) and e-mail me the change in weight over the time since they have started Topamax. E.g. W-14 would indicate a weight loss of 14 pounds since beginning Topamax.  The amount and rapidity of the weight loss has been quite gratifying to many patients most of whom have lost 20-60 lbs in 4-6 months. Some of my thinner patients have discontinued Topamax because they have lost too much weight.

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 This page last updated July 11,2005