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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 ). Patients are told at the outset that about 5% 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. 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. 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. The combination of Topamax and BOTOX seems particularly useful. 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. Recently, an increased incidence of angle closure glaucoma has been reported and patients should be warned to immediately discontinue upon developing ocular pain and consult an eye physician. Weight Loss requires a special comment. I encourage patients 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. |
