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Med adverse effects

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Patients often nickname topiramate as 'dopamax' because of the cognitive fog they experience. I wanted to open this up to discussion on how much you really see this,what dosages you see it most, and how you might combat it (or do you just substitute it)?

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For what indication are you using it?  I was part of the original topiramate trials for migraine prevention when I worked at Mayo Clinic in the 1990s. When we were done, after 10 months, we (headache department) turned against it for the AR reason.


When I came to the Pacific NW in 2002, it was being promoted like gangbusters as "the best migraine preventative in the freakin world!" They asked me to speak to on it and I refused. Then the company was able to bring in "outside headache specialist" who traveled up and down the region saying it was the best migraine drug. In return the company promoted that neurologist as the real headache specialist in our region.


In the headache world it is seen as one of thirty or so preventative medications.  I rarely start a patient on it. If they are on it and doing okay without side effects, I may continue it or increase it. I have used it to 500 MG per day (only if no side effects).  The new extended versions claim to have lower side effects and equal "control" although they can't mention migraine or headache due to indication restrictions.


There are many alternatives. Zonisamide has been shown to be equally effective and less side effects and preferred by patients.

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I was speaking on the indication of migraine prevention to discuss how to tackle such an adverse effect. I've heard patients taking B vitamins...is there any clinical data for that? Is the only option to substitute the medication?

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Alternatives for preventive treatment for migraines

Verapamil which is a calcium channel blocker





In our clinic with topamax, cognitive fog is the most common side effect with it which we will switched them to a different medication. Some patients only experience this at a higher dose 100mg bid but some at only 25mg qhs.

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I use topamax a lot and it can be especially useful for patients who have both epilepsy and headache.  It can be a great med for some and awful for others.   The cognitive issues are just one of a myriad of other possible adverse effects.  Especially important to monitor for metabolic acidosis and can cause hyperammonemia especially if used in combo with Depakote.  If the cognitive effects are disabling it's really best to switch to an alternative

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