How does topiramate fit into your treatment paradigm for prevention of episodic migraine?

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 studies of much lower quality that do not meet our modern standards of clinical trials, or even in some cases, migraine diagnosis.

2.) Topiramate can be difficult to tolerate, but many people do tole...

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 not think topiramate is much more likely to cause side effects than the others. In 12 years of practice, I have had 1 patient with acute angle closure glaucoma where we discontinued it, and ocular sy...

I agree with Dr. @Dr. First Last, 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, magnesium (especially if an ionized magnesium is less than 0.53 mmol/L) can be beneficial. The eye vitamins (Preservision/Ocuvite), the B-complex vitamins, and Vitamin D all can help. Lastly, I ...

I respectfully disagree with dear Dr. @Dr. First Last. 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, insurance companies are notorious to deny the newer anti-migraine medications. We as a community neurologists have to rely on older generic medications first before even insurance companies may c...

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 constraints.

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 randomized, double-blinded, head-to-head trial. The 50% - responder rate of erenumab was almost 80% better than that of topiramate. More impressive, however, was the difference in tolerability looking a...

I agree with Dr. @Dr. First Last. 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.

Patients, in my experience, hear about weight loss and immediately choose it from among the options available.

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 nothing other than treatment with either a triptan or a gepant a few times a month is needed.

Dominguez et al., PMID 40005053