Disclaimer: This is for informational purposes only. This does not replace the instructions you received from Dr. Anderson or any other practitioner,
constitute medical treatment, establishment of a patient-physician relationship, constitute any form of recommendation, prescription or medical
advice, or imply that the medication is appropriate or FDA approved for any condition. This information may be outdated and is not a complete
listing of instructions, doses, uses, or side effects. If this was prescribed to you, you must review this information with your pharmacist and
prescriber before starting the medication. Any medication may interfere with the ability to drive, concentrate, or operate machinery; patients must
be responsible for their own behavior and should not engage in any dangerous activity if there is any question of impairment. All medications have
side effects and drug interactions, some serious, some fatal. Let all of your practitioners and pharmacist know about every substance used. Alcohol,
herbals, or illegal drugs are not considered safe with these medications. Assume no medication is safe during pregnancy or while breast feeding. The
medication may interfere with birth control. Almost any medication can cause sleepiness, insomnia, dizziness, confusion, hallucinations, anxiety,
panic, constipation or diarrhea, headache, chest pain and nausea or vomiting, among others. These could cause physical injury, such as dizziness
causing one to fall down stairs. Many reduce blood pressure, which could cause fainting, dizziness, stroke, or other problems. Most medications
should NOT be stopped suddenly because of the risk of withdrawal. This is a supplement to the standardized drug information sheets.
Drug: TOPIRAMATE
Wayne E. Anderson, D.O.
A Medical Corporation
Chronic Intractable Pain Disorders
Headache & Facial Pain Disorders
Neurotoxin Therapy
FDA-approved uses: Migraine prevention and certain types of
seizures.
Common off-label uses: It was originally invented to prevent
seizures but has been found effective for multiple headache types.
There is evidence supportive of use for chronic migraine. It is also
used frequently off-label for neuropathic pain syndromes. Other
specialists (such as psychiatrists) use topiramate for other conditions.
Alternatives: Non-medication modalities, pain interventions and
other medications that may work in a similar manner.
Board Certified Neurology
American Board of Psychiatry & Neurology
Board Certified Pain Medicine
American Board of Psychiatry & Neurology
in association with the
American Board of Anesthesiology
Subspecialty Certified Headache Medicine
United Council for Neurological
Subspecialties
Qualified Medical Evaluator
Member of the
California Pacific Neuroscience Institute
45 Castro Street Suite 225
San Francisco CA 94114
415.558.8584 tel
415.513.4521 fax
www.wayneanderson.net
How it works: Topiramate has multiple different mechanisms of
action within the body. It works on voltage-dependent sodium
channels, at GABA-A receptors, at glutamate receptors, and as a
carbonic anhydrase inhibitor.
Side effects: Please see the standardized drug information sheet for
detailed information about risks, side effects, interactions, and other
important information. Common side effects of topiramate include
weight loss, tingling of the fingers or toes, tiredness and similar
effects. Because the medication reduces sweating, there is greater
chance of heatstroke in hot situations. A small percentage of patients
may develop kidney stones; the best way to prevent this is to drink
plenty of fluid. Importantly, there have been some reports of
glaucoma related to the medication use; when stopped, the condition
typically reverses provided it has not been long-standing. Therefore,
patients must watch for any visual disturbances or changes and
patients should continue with regular eye examinations. The dose is
changed if there is liver or kidney disease. Topamax can decrease birth
control pill effectiveness and can cause birth defects if pregnancy
occurs. And, no medication invented to prevent seizures should be
stopped suddenly, including Topamax. There are some routine blood
tests that are done occasionally while using Topamax. All medications
in this category may worsen depression, possibly resulting in suicide.
All patients should be aware and let the prescribing practitioner know
immediately of any worsening of depression. Because Topamax can
affect concentration, some patients prefer a nighttime only regimen.
Common doses: The dosing of topiramate depends on what condition is being treated. For example, it
is taken twice daily for seizures. For chronic pain and for headache disorders, the medication often is
taken only at night, which can reduce the chance of side effects during the day. The once-daily
headache type of titration scale is provided below:
Week
Nighttime dose
1
25 mg
2
50 mg
3
75 mg
4 and on
100 mg
Topiramate doses vary greatly. Headache doses typically are between 100mg and 200mg per day.
However, it is not uncommon to see doses greater than 200mg per day.
Time to effect: Unfortunately, topiramate as used for chronic pain conditions and headache disorders
may take a long time to provide clear benefit. Benefit often requires 8 weeks at a dose of 100mg or
more.
Financial: Dr. Anderson has never received payment in exchange for prescribing a medication. Dr.
Anderson has not received any payments from the pharmaceutical companies that manufacture
topiramate or brand Topamax.
Insurance coverage: Many medications, especially in painful conditions, are off-label as discussed
above. Insurance companies do not need to cover medications used off label but typically do provide
coverage for most medications that have good scientific evidence. There is no guarantee that any
medication will be covered. In general, topiramate tends to be covered for headache disorders but may
not be covered for neuropathic pain disorders.
Clinical and Scientific evidence: Some scientific evidence supportive of the use of the medication is
listed in this section. Of course, scientific information changes rapidly and the information listed may
become outdated or incorrect overnight. Topiramate is a recognized headache prophylactic medication
and it now has grade A evidence, 3/3 (maximal) scientific evidence effect and 3/3 (maximal) clinical
impression, at doses between 100-200mg per day (100mg target), and is currently FDA-approved for
headache prevention in the United States. Topiramate may be helpful for dentally-related trigeminal
pain and trigeminal neuralgia. Topiramate has evidence in relieving neuropathic pain syndromes such as
neuropathy. References:
1.
2.
3.
4.
US Headache Consortium.
Park JH, Lee SH, Kim ST. Int J Prosthodont. 2010 Jul-Aug;23(4):342-6. Pharmacologic management of trigeminal nerve injury pain
after dental implant surgery.
Lopes LS, Pereira SS, Silva LL, Figueiredo KA, Moura BA, Almeida FR, Sousa FC. Life Sci. 2009 Jan 16;84(3-4):105-10.
Antinociceptive effect of topiramate in models of acute pain and diabetic neuropathy in rodents.
Xiao W, Naso L, Bennett GJ. Pain Med. 2008 Jul-Aug;9(5):505-17. Experimental studies of potential analgesics for the treatment of
chemotherapy-evoked painful peripheral neuropathies.