Antiepileptic drugs (AEDs) are frequently used as a preventive treatment for the management of migraine. Topiramate (TPM) and valproic acid (VPA) are 2 AEDs that have demonstrated efficacy in reducing the frequency of migraine attacks, and both carry US Food and Drug Administration indications for the prevention of episodic migraine, based on level A evidence.1
“Topiramate is the most common migraine preventive in the world, used on a prescription basis, and valproic acid would be the next best choice,” Peter MacAllister, MD, told Neurology Advisor. Dr MacAllister is Medical Director of the New England Institute for Neurology and Headache and Chief Medical Officer of the New England Institute for Clinical Research and Ki Clinical Research in Stamford, Connecticut. “Other AEDs that are used for migraine but show less evidence include zonisamide and levetiracetum,” he stated.
According to Matthew Robbins, MD, a clinical neurologist at Weill Cornell Medicine and New York-Presbyterian Medical Center in New York City, “Lamotrigine may have a niche for migraine with aura specifically, but not migraine overall.” He told us that while gabapentin (GBP) is prescribed frequently, data supporting its use as a migraine preventive agent is not as strong as that of other AEDs. This was reinforced in a 2019 review by Parikh and Silberstein1 stating that, “clinical evidence has suggested that GBP is not beneficial in migraine prevention.” Similarly, they reported that oxcarbazepine “is likely ineffective for migraine prophylactic treatment.”
Levetiracetam has provoked interest compared to other AEDs, due to a unique mechanism of action of binding to the synaptic vesicle protein SV2A, and thereby blocking neuronal hyperexcitability of voltage-gated N-type calcium channels that have been implicated in migraine pathogenesis.1 Small studies of levetiracetam have indicated good efficacy and tolerability, although the evidence from multiple trials is conflicting and somewhat inconclusive, strongly suggesting the need for intensive large-scale study of this agent.1
Why AEDs Work for Migraine
Epilepsy and migraine show a 2-fold higher than average risk for comorbidity, supporting the use of AEDs for treatment of both conditions; however, the mechanisms of these drugs in migraine are not well understood.1-3 It is thought that AEDs are able to block excitation leading to cortical spreading depression that may be a central precipitator in migraine through actions on voltage- and receptor-gated ion channels that promote stabilization of neuronal membranes.1 A unique property of TPM is that it inhibits neuro-excitatory glutamate receptor activity at the cellular level, which has a pronounced effect in migraine as well as in epilepsy. A study in 2017 by Heberstreit and May3 in 27 patients found that TPM reduced blood oxygen level-dependent responses in several areas of the brain responsible for pain transmission, while also improving functional connectivity between the thalamus and somatosensory regions.3 These theories all draw an incomplete picture of how TPM works in migraine, and none have been proven as yet.
Adverse Effects of AEDs
Dr MacAllister observed that most AEDs work well when used with other agents used to treat migraine. “The biggest problem is adherence,” he said, “For example, 70% or more of migraineurs on … stop it on their own within 6 months, due to side effects.” Spritzer et al1 reported that, “it is not uncommon in clinical practice for TPM when used for migraine prevention to be given once daily, often at night, in an attempt to improve tolerability.”
The known adverse effects of TPM include a range of cognitive symptoms, such as difficulties with word-finding, concentration, memory, and slowed mental processing, as well as fatigue, dizziness, somnolence, and suicidal ideations.1 More systemic responses may include renal calculi, hypokalemia, and metabolic acidosis, with disturbances to taste (often leading to weight loss) and vision.
Zonisamide has demonstrated efficacy that is potentially comparable to TPM, with improved tolerability. The main side effects appear at doses of 200 mg/d to 500 mg/d, accumulated for more than 24 months.1 These include decreased appetite and weight, memory loss, and reduced hemoglobin levels. Rapid titration of zonisamide was also associated with potential risks for Stevens-Johnson syndrome or toxic epidermal necrolysis.
Contrary to weight loss observed with other AEDs, VPA, given at doses of 500 mg/d to 1000 mg/d for migraine prevention often produced weight gain, along with nausea, fatigue, dizziness and tremor.1 More serious effects include the potential for pancreatitis and liver failure.
Levetiracetam is associated with adverse effects, such as mood swings including irritability, hostility, and hyperactivity, as well as dizziness and somnolence.1
Of greater concern are the substantial teratogenic risks with all AED use. Both VPA and TPM have been shown to produce major congenital abnormalities that are likely to occur within the first 60 days after conception occurs.1 Unless used as a last resort, VPA and TPM “should both be avoided as a preventive agent in women of childbearing age, given their potential for birth defects and other consequences,” Dr Robbins cautioned. If AEDs are used, he noted, then contraception is highly recommended, although at higher doses, TPM can also interact negatively with contraceptives.4
“The decision to use an antiepileptic agent, or any migraine preventive agent, is based on individual factors, including side effects, route of administration, comorbidities, and most importantly for women, pregnancy considerations,” Dr Robbins said. “There is very little evidence that one preventive agent is really better than another,” he added.
1. Parikh SK, Silberstein SD. Current status of antiepileptic drugs as preventive migraine therapy. Curr Treat Options Neurol. 2019;21:16.
2. Spritzer SD, Bravo TP, Drazkowski JF. Topiramate for treatment in patients with migraine and epilepsy. Headache. 2016;561081-1085.
3. Heberstreit JM, May A. Topiramate modulates trigeminal pain processing in thalamo-cortical networks in humans after single dose administration. PLoS One. 2017;12(10):e0184406.
4. Reimers A, Brodtkorb E, Sabers A. Interactions between hormonal contraception and antiepileptic drugs: Clinical and mechanistic considerations. Seizure. 2015;28:66-70.
- Seizures and Headaches: They Don’t Have to Go Together
- Everything You Need to Know About Anticonvulsants for Migraine Treatment
- What are anticonvulsant drugs and how do they treat migraines?
- How long do they take to start working?
- How do you take anticonvulsants?
- Who should take anticonvulsants for migraine prevention?
- Who shouldn’t take anticonvulsants for migraine prevention?
- What are common anticonvulsant side effects?
- How do you choose which anticonvulsant to take?
- Which anticonvulsant does Cove offer?
- Migraines and Seizures: What’s the Connection?
- How Are Migraines Diagnosed?
- Risk Factors to Consider
- Can Migraines Lead to Seizures?
- How Are Migraines Treated?
- How Are Migraines Prevented?
- What Is the Outlook?
- What Is the Best Migraine Prevention Therapy?
- Seizure Medicines for Tension Headaches
- Topic Overview
- What is Topamax?
- Important Information
- Before taking this medicine
- How should I take Topamax?
- What happens if I miss a dose?
- What happens if I overdose?
- What should I avoid while taking Topamax?
- Topamax side effects
- What other drugs will affect Topamax?
- Further information
- More about Topamax (topiramate)
Seizures and Headaches: They Don’t Have to Go Together
Everyone has some kind of headache at one time or another. But if you have epilepsy, your chances of suffering with headaches are greater than average. Headaches may occur before seizures and are common after tonic-clonic seizures. In rare cases, the brain wave changes seen on the EEG show that a headache can actually be the only symptom of a seizure. If you have a seizure disorder, you are twice as likely to have migraine headaches. And adding worries about having a seizure to the everyday stress of life may even increase your chances of having an uncomfortable tension headache.
The most common headache associated with epilepsy is called a postictal headache, meaning that the headache occurs after seizure activity. It is estimated that 45% of people with epilepsy have postictal headache. It most frequently occurs after tonic-clonic seizures but can also follow simple and complex partial seizures. The pain of a postictal headache is widespread. It can be steady or throbbing and its intensity can range from mild to severe. These headaches usually last between about 6 and 24 hours, or sometimes even longer. They may be quite disabling, causing you to lose additional time out of your normal activities.
Less commonly, a headache may be a sign that a seizure is approaching. These headaches are called pre-ictal because they occur before the seizure activity starts. They are one type of aura, the symptoms that warn of a coming seizure. These headaches are generally brief. They can be throbbing, steady, or sharp. Pre-ictal headaches are said to affect about 20% of people who have seizures that are difficult to control, but they may be under-reported because the seizure may interfere with memory of the headache.
Another fairly common type of headache is the migraine headache. If you have migraines, they can make you quite miserable. They involve pulsating pain on one or both sides of the head, usually accompanied by other symptoms such as nausea, vomiting, or sensitivity to noise or light. About 30% of migraine attacks are preceded by an aura, which may consist of seeing zigzag flashing lights, distorted visual images, or blind spots, or feeling numbness in parts of your body. People who have migraine headaches may have only one a year or may have one every day for several weeks at a time. Migraines share some common features with epilepsy. Like seizures, they can be triggered by stress, fatigue, menstruation, and alcohol. The aura before a migraine is similar to an aura before a seizure. Even the brain activity detected by an EEG may be similarly abnormal during a migraine attack and a seizure. There is some debate among doctors about whether a migraine headache can lead straight into a seizure and be considered a pre-ictal headache.
A rare type of headache in people with epilepsy is the ictal headache. These headaches are actually seizure symptoms. Some pound like a migraine but others are sharp and steady. In some people the pain builds gradually but in others it begins suddenly. Ictal headaches are seen in all types of epilepsy, including generalized epilepsy. There is a type of epilepsy syndrome in children (called benign epilepsy of childhood with occipital paroxysms) in which 25% of the children have headache as their only symptom. Often a mistaken diagnosis of migraine is corrected only when the neurologist determines that an abnormal EEG shows epilepsy.
Is there anything you can do if you have a problem with headaches? Is there anything beyond an occasional aspirin to help you cut them short or avoid them altogether? For many people, even if you have epilepsy, the answer is yes!
Ictal headaches, the rare kind that are actually seizure symptoms, will disappear if seizure medicine can control the epilepsy brain waves. The other types of headaches generally must be treated separately from your seizure disorder.
Basically there are two medical approaches to treat your headaches. The first approach is to wait until a headache begins and then stop it. Over-the-counter pills like aspirin, Tylenol (acetaminophen) or Advil (ibuprofen) may do the job, or you may need a prescription for something like Anaprox (naproxen) or Fiorinal (a combination of butalbital, aspirin, and caffeine). For migraine headaches, which involve the blood vessels in the brain, prescription medications called triptans are especially effective. Brand names for various types include Imitrex, Zomig, Amerge, and Maxalt. The triptans are available in several forms. Which one your doctor prescribes will depend on your needs and preferences.
The second approach is to prevent headaches from occurring at all. Your doctor may call this “prophylactic” (pro-fuh-LACK-tic) treatment or “prophylaxis” (pro-fuh-LACK-sis). In this kind of treatment, you take medication every day to prevent future headaches. The seizure medicine Depakote (valproate) is approved for use in preventing headaches and might be the first choice when both headaches and seizures need treatment. Other medications often used to prevent headaches include beta-blockers such as Inderal (propranolol), calcium channel blockers such as verapamil, and Elavil (amitriptyline).
The thing to remember is that if you are having headaches in addition to your seizures, don’t be afraid to seek treatment for both conditions. Treating your headaches probably will not interfere with the control of your seizures and you will be free to enjoy life more fully!
Everything You Need to Know About Anticonvulsants for Migraine Treatment
There’s nothing more frustrating than being told to “take a painkiller and drink a glass of water” when you have a migraine. After all, if it was that simple, you probably wouldn’t be here.
We know that finding the right migraine treatment takes time. There’s no quick fix and there’s no one-size-fits-all solution. And what makes it even harder is that there’s not a lot of information out there to help you figure it out.
That’s why Cove exists. Our mission is to make it easier for migraine sufferers to get ongoing support and access to the care they need. And that’s why we’re breaking down the most common migraine treatments and explaining them to you in a language that actually makes sense. So let’s talk about anticonvulsant medications, a preventative treatment that’s been proven to work for migraine headaches.
What are anticonvulsant drugs and how do they treat migraines?
As you might know (or suspect), anticonvulsants are a prescription medication that’s most commonly prescribed for the treatment of epilepsy. However, the anti-epileptic drug also helps prevent migraines.
While it’s not entirely understood why that’s the case, some researchers believe epilepsy and migraines share some of the same traits.
There are two types of anticonvulsants used to treat migraines:
- sodium valproate (Depakote® and Depakote® ER)
- topiramate (Topamax®, Topiragen®, Qudexy DR®, and Trokendi®-XR2)
How long do they take to start working?
Anticonvulsants are preventative medication, which means it takes about one to two months for them to start working to prevent migraines (as opposed to acute medication like triptans and NSAIDs which begin working to relieve migraine pain within two hours).
According to the NIH, an anticonvulsant can be considered successful if your migraine frequency is reduced by 50%. (This is why using migraine tracking tools is so important.)
You might be doing the 50% math now and thinking that you’d like that number to be much closer to 100%. We wish that was the case, too. But until science finds a cure that prevents migraines 100% of the time, we recommend speaking to your doctor about combining your preventative treatment with acute treatment.
How do you take anticonvulsants?
You should take your anticonvulsant daily with water, with or without food. The daily dosage varies by person, so make sure to ask your doctor what’s right for you and then it as prescribed.
Who should take anticonvulsants for migraine prevention?
Anticonvulsants are a good treatment option for migraine sufferers who suffer from several migraines a month, who need additional treatment support beyond acute medication, or who can’t take acute treatment at all.
Who shouldn’t take anticonvulsants for migraine prevention?
While anticonvulsants are generally considered safe and effective, there are people who should consider other migraine treatments.
- People are currently using certain types of birth control (some anticonvulsants might prevent the birth from working)
- People who are pregnant or planning to become pregnant
- People who haven’t tried any acute migraine treatments before
That said, everyone’s different and we recommend speaking with your doctor about your specific needs and concerns. (We know, you’d prefer to get all the answers now, but were committed to providing you with the best migraine care, and in this case, that means not making any claims we can’t stand by.)
What are common anticonvulsant side effects?
While anticonvulsants are generally considered safe, like many medications, there are possible side effects.
These are the most common side effects:
- attention issues
- drowsiness and fatigue
- kidney stones
- weight loss
Note that you cannot abruptly stop taking anticonvulsants as it puts you at risk of having rebound seizures. So talk to your doctor before decreasing your usage.
You should immediately contact your doctor if you experience signs of serious allergic reaction, dizziness, or difficulty breathing while taking these medications.
How do you choose which anticonvulsant to take?
Weighing Depakote® (a.k.a. Epilim®) vs. Topamax®? They’re both effective migraine prevention treatments, but they do have different side effects. Depakote® can cause hair thinning, nausea, tremors, and weight gain. You also shouldn’t take Depakote® if you’re considering getting pregnant, because it can cause birth defects.
That’s not to say that Topamax® (a.k.a. topiramate) doesn’t have side effects. Its side effects can include numbness, tingling, difficulty finding your words, and, in some cases, weight loss.
Reading through these two descriptions might feel like you have to pick the lesser of the two evils. Dr. Philip Bain, a headache expert and Cove medical advisor, says it’s important to note that these side effects “are seen more at the doses that are used for seizures (e.g. 500 mg – 2000mg daily) than those producing benefit for migraine headache (usually 250 -1000mg max).”
Since migraines are so personal, it’s difficult to know in advance what medication will work best for you. Discuss your options with your doctor, make the best choice you can, and don’t be afraid to make changes if something doesn’t feel right.
Which anticonvulsant does Cove offer?
Cove currently offers topiramate, which is considered to be the most effective FDA-approved anticonvulsant for migraine treatment.
We know this can feel like a lot of information and you may still have questions. That’s why we work with licensed physicians to help each and every person find a treatment that’ll actually work for them (and provide ongoing support for as long as you need it). If you’d like to speak to a Cove physician about your headaches, simply .
If you’d like to keep exploring your options, we recommend reading about other migraine treatments: triptans, NSAIDs, beta blockers, and antidepressants.
The information provided in this article is not a substitute for professional medical advice, diagnosis, or treatment. You should not rely upon the content provided in this article for specific medical advice. If you have any questions or concerns, please talk to your doctor.
Topiramate is an oral medications used used to prevent migraine headaches. Call your doctor right away if you have a fever or you do not sweat during activities or in warm temperatures. Patients who take this drug may be at a greater risk of having thoughts or actions of suicide. The risk may be greater in people who have had these thoughts or actions in the past. Call the doctor right away if signs like low mood (depression), nervousness, restlessness, grouchiness, panic attacks, or changes in mood or actions are new or worse. Call the doctor right away if any thoughts or actions of suicide occur. Very bad and sometimes deadly liver problems have happened with this drug. Call your doctor right away if you have signs of liver problems like dark urine, feeling tired, not hungry, upset stomach or stomach pain, light-colored stools, throwing up, or yellow skin or eyes. This drug may cause very bad eye problems. If left untreated, this can lead to lasting eyesight loss. You can read more about topiramate’s side effects, warnings, and precautions here. Full prescribing information for topiramate is available here. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit MedWatch: https://www.fda.gov/Safety/MedWatch/default.htm or call 1-800-FDA-1088.
Photo by Frank Park on Unsplash.
Sept. 23, 2002 — Migraine headaches are among the oldest known health complaints, but doctors are still learning new tricks to help people cope and even prevent the painful attacks. In fact, a new study suggests many migraine sufferers may find relief in a drug traditionally used to treat epilepsy.
By using about half the normal dose prescribed for epilepsy, researchers found treatment with the drug Topamax cut the number of migraine episodes in half for more than 50% of the migraine sufferers.
About 500 people with chronic migraine were in the study — presented last week at a meeting sponsored by the American Medical Association in Washington, D.C.
Using a 100 mg dose, the study found 54% of the patients enrolled experienced a 50% or more reduction in the number of migraine episodes, vs. 23% who reported similar effects on the placebo. In addition, those treated with Topamax also reported a reduction in the frequency of migraine attacks, their duration, and the average number of migraine days.
Some drugs used to prevent migraines have the unwanted side effect of prompting weight gain. But researchers say Topamax also had the added benefit of inducing weight loss rather than weight gain.
“This is first medication we have that actually produced nearly 4% weight loss on average,” says study researcher Stephen Silberstein, MD, director of the Jefferson Headache Center at Thomas Jefferson University in Philadelphia.
Silberstein says there are two types of treatment for migraine: acute and preventative. Acute therapies involve taking a medication after the migraine starts to alleviate the pain and other symptoms. Preventive therapies use daily medications to reduce the frequency, duration, and severity of migraine attacks.
Triptans, a class of drugs that include Imitrex and Zomig, are commonly used to treat the migraines after they occur and work by blocking the pain receptors in the nerve endings in the nervous system.
In contrast, Silberstein says preventive drugs, such as Topamax, work in a different way to dampen down the entire pain relay system.
He says unlike epilepsy patients who must take the medication for the duration of their illness, some migraine patients may get long-term relief from short-term use of Topamax. Research shows the drug can effectively turn off the migraine process in some patients after about 3-6 months of use.
Migraines and Seizures: What’s the Connection?
If you’re affected by migraine pain, you’re not alone. Over a three-month period, it’s estimated that 17 to 23 percent of Americans have at least one migraine. People with active epilepsy are twice as likely as the general population to have migraine pain.
How Are Migraines Diagnosed?
A migraine is a type of headache that has different symptoms that are usually more intense than the more common tension headache.
To diagnose migraine headaches, your doctor will confirm the following information:
- You can answer yes to at least two of the following questions:
- Does the headache appear just on one side?
- Does the headache pulse?
- Is the pain moderate or severe?
- Does routine physical activity aggravate the pain, or is the pain so bad you have to avoid that activity?
- You have a headache with one or both of the following:
- nausea or vomiting
- sensitivity to light, sound, or odors
- You’ve had at least five of these headaches lasting four to 72 hours.
- The headaches aren’t caused by another disease or condition.
Less commonly, sights, sounds, or physical sensations accompany a migraine.
Risk Factors to Consider
Migraines are about three times more common in women than men.
Headaches, and migraines in particular, are more common among people with epilepsy than among the general population. At least one study estimates that one in three people with epilepsy will experience migraine headaches.
A person with epilepsy who has close relatives with epilepsy is more likely to experience a migraine with aura than someone without such relatives. This suggests that there’s a shared genetic link creating susceptibility to the two conditions.
Other characteristics may increase the likelihood of a seizure associated with a migraine. These include the use of antiepileptic drugs and having high body mass index.
Read more: Migraine triggers and how to avoid them “
Can Migraines Lead to Seizures?
Scientists don’t completely understand the connection between migraines and seizures. It’s possible that an epileptic episode may have an effect on your migraines. The opposite can also be true. Migraines may have an effect on the appearance of seizures. Researchers haven’t ruled out that these conditions appear together by chance. They’re investigating the likelihood that the headaches and epilepsy both arise from the same underlying factor.
To analyze any possible connection, doctors look carefully at the timing of a migraine to note whether it appears:
- before seizure episodes
- during seizure episodes
- after seizure episodes
- between seizure episodes
If you have epilepsy, it’s possible to experience both migraine and non-migraine headaches. Because of this, your doctor must consider your symptoms to determine whether your migraine and seizure are related.
How Are Migraines Treated?
Common drugs used to treat an acute attack of migraine pain include ibuprofen, aspirin, and acetaminophen. If these drugs aren’t effective, you might be prescribed a number of alternatives, including a class of drugs known as triptans.
If your migraines persist, your doctor may prescribe other medications.
Whatever drug regimen you and your doctor choose, it’s important for you to know how to navigate a medication program and to understand what to expect. You should do the following:
- Take medications exactly as prescribed.
- Expect to start with a low dose and increase gradually until the drug is effective.
- Understand that headaches probably won’t be eliminated altogether.
- Wait for four to eight weeks for any significant benefit to occur.
- Monitor the benefit that appears in the first two months. If a preventive drug provides marked relief, the improvement may continue to increase.
- Maintain a diary that documents your drug use, pattern of headache pain, and the impact of the pain.
- If the drug is successful for six to 12 months, your doctor may recommend gradually discontinuing the medication.
Migraine therapy also includes management of lifestyle factors. Relaxation and cognitive behavioral therapy have been shown to be useful in treating headaches, but research is continuing.
How Are Migraines Prevented?
The good news is that you may be able to avoid migraine pain. Prevention strategies are recommended if your migraine pain is frequent or severe and if every month, you have one of the following:
- a headache on at least six days
- a headache that impairs you on at least four days
- a headache that severely impairs you for at least three days
You might be a candidate for prevention for less severe migraine pain if every month you have one of the following:
- a headache for four or five days
- a headache that impairs you on at least three days
- a headache that severely impairs you for at least two days
An example of being “severely impaired” is being on bed rest.
There are several lifestyle habits that may increase the frequency of attacks.
You should do the following to help avoid migraines:
- Avoid skipping meals.
- Eat meals regularly.
- Establish a regular sleep schedule.
- Make sure you get enough sleep.
- Take steps to avoid too much stress.
- Limit your caffeine intake.
- Make sure that you get enough exercise.
- Lose weight if you’re overweight or obese.
Finding and testing medications to prevent migraine pain is complicated by the cost of clinical trials and the complex relationship between seizures and migraines. There’s no one strategy that’s the best. Trial and error is a reasonable approach for you and your doctor in the search for your best treatment option.
What Is the Outlook?
Migraine pain is most common in early and middle adulthood and declines substantially afterward. Both migraines and seizures can take a high toll on an individual. Researchers continue to examine these conditions alone and together. Promising research is focused on diagnosis, treatment, and the how our genetic background might affect each of these.
What Is the Best Migraine Prevention Therapy?
STOWE, VERMONT—Many treament options are available for migraine prevention. Developing customized treatment strategies for patients is essential. At the 26th Annual Stowe Headache Symposium of the Headache Cooperative of New England, Peter McAllister, MD, discussed the most efficacious migraine prevention therapies. He also gave guidance on deciding who needs preventive therapy and how to choose the right preventive treatment for each patient.
Who Needs Migraine Prevention Therapy?
Migraine prevention therapy is underutilized. Thirty-eight percent of patients could benefit from migraine prevention therapy, but only 3% to 13% are actually receiving it, according to 2012 guidelines from the AAN and the American Headache Society. Frequency of headaches and functional disability are the main criteria for deciding which patients need preventive treatment. According to the 2012 US Headache Consortium Guidelines, migraineurs with six or more headache days per month, four or more headache days with functional disability, or three or more headache days per month resulting in disability requiring bed rest, should be offered migraine preventive medication. The Canadian Prophylactic Guidelines Development Group 2012 recommended that prophylactic therapy be considered for patients whose migraine attacks have a significant impact on their lives, despite appropriate use of acute medications, trigger management, and lifestyle modification strategies.
Disability may be the more important of the two criteria. “If disabled, we really have to push and be aggressive with preventive medications,” said Dr. McAllister, Medical Director of the New England Institute for Neurology and Headache in Stamford, Connecticut. A guiding principle to consider when deciding who should receive preventive therapy is that an accurate diagnosis follows the International Headache Society, third edition (ICHD-3) guidelines. Dr. McAllister also advised doctors to make sure that patients keep headache diaries and to set realistic treatment goals. He also emphasized the importance of understanding patients’ medical and psychiatric conditions. In general, drug treatment should start with a low dose and slowly be titrated to a therapeutic dose. In addition, preventive treatment should be included as part of an overall plan that encompasses lifestyle changes, trigger reduction, and a strategy for withdrawal of medication.
The FDA has approved several drugs for migraine prevention, including divalproex sodium, topiramate, propranolol, timolol, and methysergide. Of all classes of migraine preventive therapy, antiseizure medications have the most support in the data. Topiramate is “a top choice” for migraine prevention because Class I evidence supports its efficacy and it is fairly well tolerated, said Dr. McAllister. Topiramate was also approved for children based on a double-blind study of participants between ages 12 and 17. Divalproex, another antiseizure medication, has high efficacy, but side effects such as weight gain, hair loss, tremor, teratogenicity, increased liver function tests, and increased risk for pancreatitis make the drug unattractive to many.
Antihypertensive medicines also may be used for migraine prevention. Much research supports the efficacy of beta blockers in migraine prevention, and doctors can help patients manage their associated side effects. Metoprolol, a beta blocker, may be more tolerable for someone with asthma or glucose issues because it is selective for β1. Although physicians have used verapamil, a calcium channel blocker, for migraine prevention, the most recent guidelines give a Level U recommendation for its use because of conflicting or insufficient evidence. Lisinopril, an angiotensin-converting-enzyme inhibitor, and candesartan, an angiotensin receptor blocking agent, have good side effect profiles. These drugs are recommended for patients with mild hypertension. American guidelines provide a Level C recommendation of clonidine, but Canadian guidelines recommend against using the drug because of insufficient evidence and concern about the side effects.
Neurologists who seek to avoid pharmacologic treatments may choose options such as biologics or neurostimulators. OnabotulinumtoxinA injections are approved for patients with chronic migraine. Administered properly, the treatment has no systemic side effects and few local side effects.
In 2014, the FDA allowed the Cefaly device, which stimulates the trigeminal nerve, to be marketed for the prevention of migraine. In 2013, 67 patients with migraine were randomized to supraorbital stimulation with Cefaly or sham stimulation. The number of headache days per month decreased from seven to five among the participants randomized to Cefaly. Patients who received sham stimulation had no change in this end point.
Some patients may be interested in complementary or alternative treatment options like biofeedback. Biofeedback allows patients to monitor and change certain physiologic parameters (eg, muscle contraction and skin temperature) and is used to treat insomnia and anxiety. This therapy can be combined with a migraine preventive drug for the best results. Controlled studies indicate that biofeedback can result in a 45% to 60% headache reduction. When combined with medication, biofeedback reduces headache by more than 70%. Children and adolescents can also benefit from this treatment.
Seizure Medicines for Tension Headaches
Seizure medicines are drugs that are used to treat seizures. Seizure medicines are also used to prevent migraine headaches . And they may be used to help prevent tension headaches in some people. There is not good evidence for their use in preventing tension headaches, but your doctor may think that one of these medicines will help you if you have chronic tension headaches:
- Gabapentin (for example, Neurontin)
- Topiramate (for example, Topamax)
- Valproate (for example, Depakene)
Side effects of topiramate can include:
- A prickling or tingling sensation in the hands and feet.
- Lack of coordination.
- Loss of appetite and weight loss.
- Inability to concentrate or speak clearly.
Gabapentin is a well-tolerated drug that usually causes only mild side effects. These often go away within 1 to 2 weeks and include:
- Drowsiness and fatigue.
- Weight gain.
- Foot swelling.
Side effects of valproate can include:
- Tremor or shakiness.
- Hair loss.
- Weight gain.
- Headache pain that is different than pain from a migraine headache.
Do not use valproate if you are pregnant, breastfeeding, or planning to get pregnant. If you need to use this medicine, talk to your doctor about how you can prevent pregnancy.
Women who use topiramate during pregnancy have a slightly higher chance of having a baby with birth defects. If you are pregnant or planning to get pregnant, you and your doctor must weigh the risks of using this medicine against the risks of not treating your condition.
The U.S. Food and Drug Administration (FDA) has issued a warning on seizure medicines and the risk of suicide and suicidal thoughts. The FDA does not recommend that people stop using these medicines. Instead, people who take seizure medicine should be watched closely forwarning signs of suicide . People who take seizure medicine and who are worried about this side effect should talk to a doctor.
Generic Name: topiramate (toe PYRE a mate)
Brand Names: Qudexy XR, Topamax, Topamax Sprinkle, Topiragen, Trokendi XR
Medically reviewed by Sophia Entringer, PharmD Last updated on Jan 2, 2019.
- Side Effects
What is Topamax?
Topamax (topiramate) was originally FDA-approved as a seizure medicine, also called an anticonvulsant. Topiramate is used to treat seizures in adults and children who are at least 2 years old.
Topamax is also used to prevent migraine headaches in adults and teenagers who are at least 12 years old. This medicine will only prevent migraine headaches or reduce the number of attacks. It will not treat a headache that has already begun.
Topamax may also be used for purposes not listed in this medication guide.
Topamax may cause vision problems that can be permanent if not treated quickly. Call your doctor right away if you have a sudden decrease in vision.
Topamax can decrease sweating and may cause life-threatening hyperthermia (especially in children). Avoid becoming overheated or dehydrated. Tell your doctor if you have decreased sweating, high fever, and hot dry skin.
Some people have thoughts about suicide while taking seizure medicine. Stay alert to changes in your mood or symptoms. Report any new or worsening symptoms to your doctor.
Do not stop using Topamax suddenly or you could have increased seizures.
Before taking this medicine
You should not use Topamax if you are allergic to topiramate. You should not use extended-release topiramate if you have metabolic acidosis (high levels of acid in your blood) and are also taking metformin for diabetes.
To make sure Topamax is safe for you, tell your doctor if you have ever had:
glaucoma or other eye problems;
diabetes, or metabolic acidosis;
kidney disease, kidney stones, or dialysis;
lung disease, breathing problems;
mood problems, depression, or suicidal thoughts or actions;
an eating disorder;
soft or brittle bones (osteoporosis, osteomalacia);
a growth disorder; or
if you are sick with diarrhea.
Topiramate can increase the level of acid in your blood (metabolic acidosis). This can weaken your bones, cause kidney stones, or cause growth problems in children or harm to an unborn baby. You may need blood tests to make sure you do not have metabolic acidosis, especially if you are pregnant.
Some people have thoughts about suicide while taking an anticonvulsant. Your doctor will need to check your progress at regular visits while you are using Topamax. Your family or other caregivers should also be alert to changes in your mood or symptoms.
Do not start or stop taking Topamax during pregnancy without your doctor’s advice. Topiramate may increase the risk of low birth weight and cleft lip and/or cleft palate in a newborn. There may be other seizure medicine that can be more safely used during pregnancy. Tell your doctor right away if you become pregnant.
Topiramate can make birth control pills less effective. Use a barrier form of birth control (such as a condom or diaphragm with spermicide) to prevent pregnancy while taking Topamax.
Topiramate can pass into breast milk. It may not be safe to breast-feed a baby while you are using this medicine. Ask your doctor about any risks. Tell your doctor if you are breast-feeding.
How should I take Topamax?
Take Topamax max exactly as prescribed by your doctor. Follow all directions on your prescription label. Your doctor may occasionally change your dose. Do not take this medicine in larger or smaller amounts or for longer than recommended.
Topamax can be taken with or without food.
Do not crush, chew, or break a Topamax tablet. Swallow the tablet whole.
Topamax Sprinkle Capsule can be swallowed whole. Or you may open the capsule and sprinkle the medicine into a spoonful of applesauce or other soft food. Swallow right away without chewing. Do not save the mixture for later use.
Carefully follow the swallowing instructions for your medicine.
Topiramate doses are based on weight in children. Your child’s dose needs may change if the child gains or loses weight.
Drink plenty of liquids while you are taking topiramate, to prevent kidney stones or an electrolyte imbalance.
While using Topamax, you may need frequent blood tests. If you need surgery, tell the surgeon ahead of time that you are using this medicine. Any medical care provider who treats you should know that you take seizure medication.
Do not stop using Topamax suddenly, even if you feel fine. Stopping suddenly may cause increased seizures. Follow your doctor’s instructions about tapering your dose.
Call your doctor if your seizures get worse or you have them more often while taking Topamax.
Store at cool room temperature away from moisture, light, and high heat. Keep the bottle tightly closed when not in use.
What happens if I miss a dose?
Take the missed dose as soon as you remember. Skip the missed dose if you are more than 6 hours late in taking it. Wait until your next scheduled dose. Do not take extra medicine to make up the missed dose.
Call your doctor for instructions if you miss two or more doses.
What happens if I overdose?
Seek emergency medical attention or call the Poison Help line at 1-800-222-1222.
Overdose symptoms may include drowsiness, agitation, depression, double vision, thinking problems, problems with speech or coordination, fainting, and seizures (convulsions).
What should I avoid while taking Topamax?
Do not drink alcohol. Dangerous side effects or increased seizures may occur.
Avoid becoming overheated or dehydrated in hot weather. Topiramate can decrease sweating and increase body temperature, leading to life-threatening dehydration (especially in children).
Ketogenic or “ketosis” diets that are high in fat and low in carbohydrates can increase the risk of kidney stones. Avoid the use of such diets while you are taking Topamax.
Topiramate may cause blurred vision or impair your thinking or reactions. Avoid driving or operating machinery until you know how this medicine will affect you.
Also avoid activities that could be dangerous if you have an unexpected seizure, such as swimming or climbing in high places.
Topamax side effects
Get emergency medical help if you have signs of an allergic reaction to Topamax: hives; difficult breathing; swelling of your face, lips, tongue, or throat.
Report any new or worsening mood symptoms to your doctor, such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), depressed, or have thoughts about suicide or hurting yourself.
Call your doctor at once if you have:
vision problems, eye pain or redness, sudden vision loss (can be permanent if not treated quickly);
confusion, problems with thinking or memory, trouble concentrating, problems with speech;
dehydration symptoms – decreased sweating, high fever, hot and dry skin;
signs of a kidney stone – severe pain in your side or lower back, painful or difficult urination;
signs of too much acid in your blood – irregular heartbeats, feeling tired, loss of appetite, trouble thinking, feeling short of breath; or
signs of too much ammonia in your blood – vomiting, unexplained weakness, feeling like you might pass out.
Common Topamax side effects may include:
fever, weight loss;
numbness or tingling in your arms and legs;
flushing (warmth, redness, or tingly feeling);
headache, dizziness, drowsiness, tired feeling, slow reactions;
mood problems, feeling nervous;
nausea, diarrhea, stomach pain, loss of appetite, indigestion;
cold symptoms such as stuffy nose, sneezing, sore throat; or
changes in your sense of taste.
This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
What other drugs will affect Topamax?
Taking Topamax with other drugs that make you sleepy can worsen this effect. Ask your doctor before taking a sleeping pill, opioid pain medication, muscle relaxer, or medicine for anxiety or depression.
Tell your doctor about all your current medicines and any you start or stop using, especially:
birth control pills; or
other seizure medications, such as divalproex (Depakote) or valproic acid (Depakene).
This list is not complete. Other drugs may interact with topiramate, including prescription and over-the-counter medicines, vitamins, and herbal products. Not all possible interactions are listed in this medication guide.
Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use Topamax only for the indication prescribed.
Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.
Copyright 1996-2020 Cerner Multum, Inc. Version: 17.01.
More about Topamax (topiramate)
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- Drug class: carbonic anhydrase inhibitor anticonvulsants
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