From the Guidelines
For a patient on Topamax (topiramate) 25mg daily who is still experiencing breakthrough migraines, the next treatment step would be to consider adding a second preventive medication from a different class, such as a CGRP monoclonal antibody, as the current dose of topiramate may not be sufficient to achieve optimal migraine prevention. According to the most recent guideline from the American College of Physicians 1, the main goal of prevention is to reduce the frequency and severity of migraine headache, and considerations for preventive pharmacologic treatments include frequency, severity, duration, and functional disability. The guideline also mentions that many pharmacologic treatments were originally developed for conditions other than migraine prevention and are used off-label for this indication, and that newer options such as CGRP antagonists and monoclonal antibodies have been granted FDA approval for migraine prevention. Additionally, a study published in Nature Reviews Neurology 1 recommends considering CGRP monoclonal antibodies as third-line medications for migraine prevention, and also suggests using beta blockers, topiramate, or candesartan as first-line medications, and flunarizine, amitriptyline, or sodium valproate as second-line medications. Some key points to consider when adding a new medication include:
- Ensuring the patient is aware of potential side effects and interactions with their current medication regimen
- Gradually titrating the dose of the new medication to minimize side effects
- Monitoring the patient's response to the new medication and adjusting the treatment plan as needed
- Considering the patient's values and preferences when selecting a new medication
- Ensuring the patient has an appropriate rescue medication, such as a triptan, for breakthrough headaches.
From the FDA Drug Label
It is recommended that therapy be initiated at 25-50 mg/day followed by titration to an effective dose in increments of 25-50 mg/week The recommended total daily dose of Topiramate as adjunctive therapy in adults with partial seizures is 200-400 mg/day in two divided doses
The patient is currently on 25mg daily and still experiencing breakthrough migraines. The next treatment step would be to titrate the dose in increments of 25-50 mg/week until an effective dose is reached, with a target dose of 200-400 mg/day 2.
From the Research
Treatment Options for Breakthrough Migraines
- For a patient on Topamax (topiramate) 25mg daily still experiencing breakthrough migraines, several options can be considered:
- Increasing the dose of topiramate, as studies have shown that doses up to 100mg daily can be effective in reducing migraine frequency 3, 4
- Switching to an extended-release (XR) formulation of topiramate, which may have a more favorable pharmacokinetic profile and reduce cognitive side effects 3
- Adding another preventive medication, such as divalproex sodium, although head-to-head studies comparing topiramate and divalproex sodium are limited 5
- Considering other prophylactic drugs, such as beta-blockers, methysergide, or amitriptyline, depending on the patient's specific needs and medical history 6
Dose Titration and Tolerability
- When increasing the dose of topiramate, it is recommended to do so gradually, as cognitive complaints and other side effects are more common at higher doses 7, 4
- The efficacy and tolerability of topiramate can vary between patients, and some may respond to lower doses while others require higher doses 4
- Regular follow-up and monitoring of side effects and treatment response are essential to optimize treatment outcomes 5
Alternative Treatment Approaches
- If the patient continues to experience breakthrough migraines despite optimal dosing of topiramate, alternative treatment approaches, such as botulinum toxin injections or nerve blocks, may be considered 3
- A comprehensive treatment plan should take into account the patient's individual needs, medical history, and lifestyle to achieve optimal migraine management 6