CORTICAL SPREADING DEPRESSION
100 mg, divided into two doses daily,” says Mark W. Green, MD, FAAP, director of Headache and Pain Medicine at the Mount Sinai School of Medicine in New York City.“ It is best to start with 15 or 25 mg and increase that dose weekly over four to six weeks, to 90 to 100 mg.” But the regimen generally doesn’ t end at six weeks.
“ The longer we keep you on it, the higher the chances are that you’ ll do well without it,” Dr. Green says.“ We don’ t assume that we are going to treat you forever. I might treat someone for a year and slowly reduce the drug and see if they still need it, and often, they do fine.”
In a 2006 study of 970 migraineurs, patients who received topiramate( regardless of dose) during a clinical trial saw their migraines decrease from three to 12 attacks per month, to an average of 3.4 attacks per month after the first six months of treatment. After eight months, patients saw their migraines decrease to an average of 2.2 attacks per month. 8 It is not known how long this trajectory continues, but it seems to be maintained even after the drug is discontinued. 1
Patti Havens, 52, is among those who saw the benefit increase over time.
“[ At first ] I was like,‘ Oh my gosh, that stuff is brutal! I don’ t want to take it!’” says Havens, who lives in Claremont, Calif. and works in her husband’ s law office.
But Havens says she was missing out on life and needed to manage her migraines. Shortly after she started taking Topamax ®( topiramate), the number of migraines decreased from 12 to 15 a month to just three migraines during her first 18 months on the drug. Then suddenly, her migraines disappeared altogether.
SLIMMING EFFECT
In addition to curbing migraines, some migraineurs have also noticed that topiramate triggers weight loss. In a 2012 study, which compared topiramate to the antidepressant medication amitriptyline, patients treated with topiramate lost an average of five pounds during the 26-week trial, while patients treated with amitriptyline gained about five pounds. 9
“ It’ s one of the few migraine drugs that can cause weight loss and doesn’ t cause weight gain,” Dr. Green says.“ Obesity is a risk factor for the progression of headaches, so if you can help reduce weight, this can have a therapeutic effect on migraine.”
Still, while the drug may commonly cause weight loss, it is not approved by the FDA for that effect. Therefore, though migraineurs may find themselves losing weight on the drug, headache specialists prescribe it for migraine prevention alone— not for the promotion of weight loss.( On a separate note, the drug Qsymia™, which combimes topiramate and phen-
8. Rapoport et al.“ Long-term Migraine Prevention with Topiramate: Open-label Extension of Pivotal Trials.” Headache. 2006; 46( 7): 1151-1060.
9. Dodick et al.“ Topiramate Versus Amitriptyline in Migraine Prevention: A 26-week Multicenter, Randomized, Double-blind, Doubledummy, Parallel-group Noninferiority Trial in Adult Migraineurs.” Clinical Therapeutics. 2009; 31:542-559.
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