Thread by @CSWhiteMD

Let’s talk about #topiramate for #migraine. Love it or hate it, you’re probably gonna prescribe it for your patients. Unfortunately, I see a lot folks prescribe it in a way that it is either not effective or causes side effects, leading to the general disdain for the med. A 🧵1/n

This #tweetorial is more for medical providers but patients can learn from it to. Here are some ways to take topiramate that may lead to decrease in frequency and severity of migraine symptoms with less side effects. #MedTwitter #NeuroTwitter #MedEd 2/n

Topiramate one of the cheapest migraine preventives and it is usually covered by insurance. It also often needs to be trialed due to step therapy before other treatments can be prescribed. It’s also an effective med. But only if prescribed right. 3/n

Topiramate was not originally made for #migraine prevention. It’s an antiseizure med. It targets sodium channels and carbonic anhydrase primarily as well as other neurotransmitters. Because it’s so broad spectrum in its mechanism, it’s more likely to have side effects. 4/n

But in my experience, hitting more targets leads to a more effective #migraine med. Because migraine is not due to just one specific mechanism. It’s different in every person and it’s different between people. But more targets means more side effects. 5/n

So what do we do to mitigate these effects? Start low and go slow. Typical effective dose is 100-200mg daily, divided up BID. But you don’t want to start right away on that dose because the side effects will be brutal. 6/n

I typically start with 25mg nightly for a week and then go up by 25mg every week so in 4 weeks, patient will be up to 100mg nightly. If they are getting side effects, they can try to lower their dose or maintain the dose until they adjust. 7/n

Some people may only need 25-50mg for good effect. You wouldn’t know if you start them on the higher dose. Sometimes a low dose topiramate combined with other preventives is a better option and less side effects. 8/n

Also let your patients know about these side effects ahead of time, especially common ones like fatigue, parasthesias. Work to figure out if the cognitive fog is due to migraine or medicine. Change times when you take the dose to see if it’s more tolerated. 9/n

Too many people miss out on what can be an effective med because it is not started gently and they are not warned of potential side effects. And also, discuss if they’re willing to trade the side effects for migraine relief. 10/n

I had paresthesias on topiramate. But I didn’t mind them if it meant I had migraine relief. And you’ll find that some patients are willing to make that trade off. Obviously things like kidney stones or glaucoma would be a reason to stop the med. 11/n

Now not everyone is going to find it effective or tolerable but it’s definitely worth giving a try. There is also the extended release form, Trokendi, which has less side effects. Definitely worth trying if it’s affordable. 12/n

The other important thing to educate your patients on is that, unfortunately, topiramate takes a LONG time to be effective. If you’re taking 4 weeks just to get to the therapeutic dose, you still have 8-12 weeks to know if it’s effective. 13/n

Explain to patients that it’s not like you take this for 12 weeks and then on week 13, you are migraine free. Rather, have them notice how many symptom free days they have or decreased symptoms or if their rescues work better. We’re looking for gradual changes here. 14/n

Way too many patients come to me having taken 25mg of topiramate for one week and stopped saying it didn’t work. They did not give it time to work. Make sure you educate your patients on this process. You may find more people benefit from it. 15/n

Now it’s obviously not the med for everyone, but I think a lot more people can benefit from it. Yes, we have the CGRP meds & their minimal side effects. But that’s because they are specific targets and if your migraine isn’t due to that pathway, it may not help. 16/n

Not to mention our current healthcare system makes them very difficult to access. So sometimes topiramate is the only option. So why not make it a good option? 17/n

Main take home points:

1. Topiramate is broad spectrum which could make it more effective but also with more side effects.

2. Start low and go slow to mitigate those side effects.

3. Decide if some of those side effects are worth trading for migraine relief. 18/n

4. Give it time to work. And don’t expect a sudden change but a gradual one.

5. You may do better with a lower dose and combining with other preventives.

6. You probably won’t get newer meds covered unless your patient has tried topiramate so you might as well try it. 19/n

Topiramate is not the perfect med. It’s not the silver bullet. But if used appropriately, you may find it’s a much better drug than the reputation it’s given. #NeuroTwitter #MedTwitter #MedEd #Migraine #HeadacheDisorders 20/end