How does topiramate fit into your treatment paradigm for prevention of episodic migraine?
In light of 2025 ACP guidelines on episodic migraine prevention placing topiramate as a 3rd line agent due to discontinuation from adverse events
Answer from: at Academic Institution
1) Topiramate has excellent evidence for efficacy, including better than the evidence for beta blockers, amitriptyline, and venlafaxine which this guideline recommended as first-line. I have a hard time saying these meds should be recommended as first-line over topiramate due to the reliance on old ...
Comments
at AdventHealth Insurance companies will generally not approve or ...
I use topiramate as a first-line preventative medication. I would consider topiramate, TCAs, beta-blockers, and venlafaxine to be the first line. I may choose a medication based on comorbidities such as mood disorder, insomnia, obesity, hypertension, etc. All of these can cause side effects and I do...
Comments
at Johns Hopkins All Childrens Hospital Neurology Dr. @Stakic, did your patient with acute angle clo...
at UPMC It was within the first month of starting topirama...
I respectfully disagree with dear Dr. @Spierings. In my practice, I have seen topiramate has been relatively effective with 80% reduction of migraines frequency and intensity when it reaches to 2 months of duration at 25 to 50 mg BID with minimal side effects in younger patients.
As everyone knows,...
I prescribe Topiramate for migraine prevention in patients who:
Have dual purposes, such as weight-loss considerations.
Do not have contraindications like pregnancy, a history of kidney stones, or closed-angle glaucoma.
Need to try other medications like CGRP inhibitors due to insurance constra...
I agree with Dr. @Stakic. None of my patients could afford a CGRP as a first-line treatment. The side effects of topiramate (paresthesias, cognition changes, and weight loss) occur early and resolve completely. Longer-term effects (kidney stones) are an issue only if years of treatment have occurred...
As far as I am concerned, topiramate has no place anymore in migraine prevention, especially because of poor tolerability with the potential of affecting cognitive functioning. In the relatively low dose of 50 -100 mg daily, it was compared with erenumab, 70 or 140 mg subcutaneously monthly, in a ra...
Comments
at Greater Boston Headache Center at Boston Advanced Medicine It seems like others are less in favor of topirama...
at Hendricks Neurology Respectively disagree. In my 30-year experience, p...
I agree with Dr. @Stakic, I would add to his list of suggestions zonisamide, which I find lighter than topiramate in terms of cognitive suppression, with overall better tolerability. I would also add candesartan, 4-16 mg, to the list of migraine prophylactic medications. As others have mentioned, ma...
Thank you all for this interesting discussion. Most of my patients really want to work with a natural treatment first. My own experience is that with improvements in sleep, exercise, and diet along with 400 magnesium oxide, about 50% of patients have their headaches reduced to the point where nothin...
Insurance companies will generally not approve or ...