An anticonvulsant medication also used for migraine prevention and as an alternative for IIH. Has weight loss properties.
Drug Class: anticonvulsant
Topiramate is an anticonvulsant medication with multiple uses in neuro-ophthalmology. It's used for migraine prevention, as an alternative to acetazolamide for IIH, and for some other conditions. Its weight loss effect can be beneficial for patients with IIH.
Key Takeaways
- Used for migraine prevention and IIH
- Causes weight loss—beneficial for IIH
- Has carbonic anhydrase inhibitor effects (like acetazolamide)
- Can cause cognitive side effects ("brain fog")
- Requires gradual dose increases
How It Works
Topiramate works through multiple mechanisms including blocking sodium channels, enhancing GABA activity, and inhibiting carbonic anhydrase. This last effect makes it useful for IIH, similar to acetazolamide.
Common Uses
- Migraine prevention
- Idiopathic intracranial hypertension—alternative to acetazolamide
- Epilepsy
- Weight management (as adjunct)
Dosing
- Start low and increase slowly ("start low, go slow")
- Usually 25-50mg daily initially
- Increase weekly by 25mg
- Migraine prevention: typically 50-100mg daily
- IIH: may need higher doses
Side Effects
Common
- Cognitive effects—word-finding difficulty, mental slowing
- Tingling (paresthesias)
- Fatigue
- Weight loss
- Altered taste
- Decreased appetite
Less Common
- Kidney stones
- Metabolic acidosis
- Mood changes
- Vision changes (acute glaucoma—rare but urgent)
- Heat intolerance (decreased sweating)
Important Precautions
Acute glaucoma warning: Rarely, topiramate can cause acute angle-closure glaucoma with eye pain, vision loss, and red eye. This is a medical emergency—stop the medication and seek immediate care.
Monitoring
- Electrolytes and bicarbonate
- Kidney function
- Report any eye pain or vision changes immediately
Tips for Taking Topiramate
- Increase dose gradually to minimize side effects
- Stay hydrated to reduce kidney stone risk
- Cognitive effects often improve with time
- Take at night if it causes drowsiness
Frequently Asked Questions
Why do I feel "foggy"?
Cognitive effects ("Dopamax" as some call it) are common, especially at higher doses. This often improves over time. If severe, discuss lowering the dose with your doctor.
Will I lose weight?
Many patients do experience weight loss. This can be beneficial for IIH patients, where weight loss is part of treatment. However, don't use it primarily for weight loss.
Can I drink alcohol?
Alcohol may worsen cognitive side effects and increase sedation. Use caution and discuss with your doctor.
Medical Disclaimer: This information is for educational purposes only and does not replace professional medical advice.
Medically Reviewed Content
This article meets our editorial standards
- Written by:
- Hashemi Eye Care Medical Team
- Medically reviewed by:
- Board-Certified Neuro-Ophthalmologist (MD, Neuro-Ophthalmology)
- Last reviewed:
- January 30, 2025