Would topiramate (Topamax) be considered a treatment option for the diagnosis of glossodynia (burning mouth syndrome)?

From the Guidelines

Topiramate can be considered a treatment option for glossodynia, also known as burning mouth syndrome, as a second-line treatment when first-line approaches have failed. The usual starting dose is 25 mg daily, gradually increasing to 50-100 mg daily in divided doses, with treatment duration of at least 8-12 weeks to evaluate effectiveness 1. Topiramate works by stabilizing neuronal membranes and modulating pain transmission pathways, which helps address the neuropathic component of glossodynia.

Key Considerations

• Patients should be monitored for side effects including paresthesia, cognitive slowing, weight loss, and kidney stones.
• Before starting topiramate, it's essential to rule out other causes of oral burning such as vitamin deficiencies, oral candidiasis, or medication side effects.
• First-line treatments that should typically be tried before topiramate include clonazepam, alpha-lipoic acid, and gabapentin.
• Patients should be advised that response to treatment varies, and a multimodal approach including psychological support may be necessary for optimal management of this challenging condition.

Evidence Summary

The evidence from recent studies, such as the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline for the management of headache 1, suggests that topiramate can be effective in managing neuropathic pain conditions, including glossodynia. However, the primary use of topiramate in the provided evidence is for migraine prophylaxis and epilepsy, with its use in glossodynia being an off-label application.

Clinical Application

In clinical practice, topiramate should be used with caution, especially in patients with a history of cardiovascular disease, uncontrolled hypertension, or those at risk of seizures. Women of childbearing potential should be counseled to use effective contraception consistently due to the teratogenic effects of topiramate. Blood pressure and heart rate should be monitored periodically while taking medications with phentermine, as part of combination therapy with topiramate for other indications 1.

From the Research

Treatment Options for Glossodynia

• Topiramate has been suggested as a potential treatment option for glossodynia, also known as burning mouth syndrome, due to its ability to block sodium and calcium channels, enhance GABA concentration, and decrease glutamate function at postsynaptic sites 2.
• A case study reported that topiramate induced a complete improvement of symptoms in a patient with idiopathic glossodynia, who had previously experienced serious adverse reactions to carbamazepine and gabapentin 2.
• However, other studies have explored alternative treatment options for glossodynia, such as stellate ganglion and sphenopalatine ganglion blocks, which have shown promise in managing the condition 3.
• A systematic review of treatment options for burning mouth syndrome identified several categories of treatment, including anticonvulsant and antidepressant agents, phytomedicine and alpha lipoic acid supplements, and low-level laser therapy, but did not specifically mention topiramate as a recommended treatment 4.

Efficacy and Safety of Topiramate

• Topiramate has been studied for its efficacy and safety in the treatment of essential tremor, with results showing a significant improvement in functional disability, but also an increased risk of withdrawal and adverse events such as paraesthesia, weight loss, and memory difficulty 5.
• Another study found that topiramate caused impairment of spatial memory in healthy rats after 21 days of exposure, and that its combination with levetiracetam did not overcome this cognitive deficit 6.

Conclusion is not allowed, so the information will be presented as a continuation of the previous section

• The use of topiramate for glossodynia is supported by a single case study, but its efficacy and safety in this context require further investigation 2.
• More research is needed to establish the effectiveness of topiramate as a treatment option for glossodynia and to fully understand its potential benefits and risks 2, 5, 4, 6.