‹ How Long & How Likely To Work, Comparisons with Other Meds | TopamaxPagesIndex | Pros & Cons, Interesting Stuff Your Doctor Didn’t Tell You ›
Crazy Meds Comprehensive Topamax pages

One of the most important aspects of any medication is how to go about taking it. This includes:

• how much to take (the dosage or dose)
• when and how often to take it (dosing schedule or doses)
• how much to start with and how to increase the dose/dosage until you’re taking the target amount (titration or titration schedule).

This information is always in the PI sheet, is usually in the information for patients leaflets, most doctors will give you some idea of what it will be like, and this is what every pharmacist is trained and paid to tell you.

We here at Crazy Meds often disagree with the official schedules found in the PI sheets. We usually advocate starting at a lower dosage than recommended. One of our core philosophies is increasing the dosages as slowly as one’s condition allows, and staying at the dosage that works instead of a target dosage¹. More and more doctors are agreeing with us². You and your doctor can always discuss increasing the dosage when you need to in advance.
And since you never really know how a drug might affect you, it’s best to start when you have some time off of work. Like Friday night / Saturday morning, or your equivalent. Better still would be to get someone to stay with you or at least check on you frequently, especially if you’re the primary caretaker of young children and similar critters.

1.  Topamax’s (topiramate)’s dosage and doses

For migraines, other headaches, and epilepsy the usual way is half your daily dosage in the morning and half at night. If you’re taking only one tablet, though, just take it at night. Never split a Topamax tablet. The sprinkle capsules you can open up and divide as best you can if you want.

The effective dosage for migraines is usually 50–100mg a day. Sometimes dosages up to 200mg a day are required.

The effective dosage for epilepsy is usually 200–400mg a day. Lower dosages sometimes work. Dosages above 400mg a day are sometimes required, usually if you’re taking Tegretol or Dilantin (phenytoin), but some people just need more Topamax. Topamax is rated as safe for adults in dosages up to 1,000mg a day³, although 800mg a day is the upper limit of efficacy under any circumstances.

For off-label uses it’s usually the same, i.e. you take anywhere between 50 and 400mg a day, divided into two doses, but not always. E.g. for ultradian rapid cycling you’ll need to take your Topamax four times a day, although the doses don’t need to be the same size.

---

---

2.  Best way to take / special instructions for taking Topamax (topiramate)

If you are also taking Tegretol (carbamazepine) and/or Dilantin (phenytoin) you’ll need to take twice as much Topamax. Both of those meds double the rate at which Topamax is cleared from your system.

If you experience nausea or similar problems, try taking Topamax with food. The sprinkles were designed to be mixed into soft foods like pudding. You’ll need to scroll down to see what I’m referring to. Ortho-McNeil keeps taking those instructions out and putting them back in⁴.

3.  Topamax’s (topiramate)’s titration (dosage increase)

For migraines the initial dose is 25mg a day, increased by 25mg a day each week as needed until you reach 100mg a day, usually divided into two doses. Lots of people have reported (anecdotal evidence) that Topamax will work for migraines at 25mg a day. Lots of studies and trials show that 50 mg a day will work for 25–50% of of those who take that dosage. From one of the clinical trials:

Quote: The responder rate was significantly greater with topiramate at 50 mg/d (39%, P = .01), 100 mg/d (49%, P<.001), and 200 mg/d (47%, P<.001) vs placebo (23%). Reductions in migraine days were significant for the 100-mg/d (P = .003) and 200-mg/d (P<.001) topiramate groups. Rescue medication use was reduced in the 100-mg/d (P = .01) and 200-mg/d (P = .005) topiramate groups.

As you can see, 200mg didn’t work much better than 100mg. Other studies have shown that if 100mg a day doesn’t work, 200mg a day might, but if 200mg a day doesn’t work, don’t bother going higher than that unless you’re low on med options.

For epilepsy it’s complicated, although nowhere near as complicated as Lamictal’s.⁵ Here’s the party line from the PI sheet for reaching the optimal dosage of 400mg a day when you aren’t taking anything else:

	Morning Dose	Evening Dose
Week 1	25 mg	25 mg
Week 2	50 mg	50 mg
Week 3	75 mg	75 mg
Week 4	100 mg	100 mg
Week 5	150 mg	150 mg
Week 6	200 mg	200 mg

To which we say, “BULLSHIT!” So does Dr. Devinsky, Dr. Faught, Drs. Silbersein & Marmura, and pretty much everyone else with a clue about how things work in the real world. Unless you are flopping around on the floor with a seizure at least once a day, every day, there is no need to increase the dosage that rapidly.

Here’s the Crazy Meds suggestion to discuss with your doctor:

	Morning Dose	Evening Dose
Week 1	25 mg	25 mg
If your seizures stopped
Week 2	25 mg	50 mg
Did you have a seizure? No?
Week 3	50 mg	50 mg
How about this week? Great news!
Week 4	50 mg	50 mg

Still no seizures? Talk to your doctor about dosage increases from this point forward.
And that’s where you stay, unless you have another seizure. If you experience really bad side effects after a dosage increase that don’t get better by the day of your next scheduled increase, then discuss the dosage adjustment with your doctor.
If your seizures didn’t stop at Week 2, or whenever, follow the 50mg a day increase as laid out in the PI sheet until you reach a dosage where they do stop and stay at that dosage.

No matter what your dosage is, you’ll probably need to adjust it later, mainly to deal with side effects. That usually means decreasing, or even increasing the dosage by 25–50mg a day. Yup, even though the side effects tend to be dosage-dependent⁶, which usually means they get worse as you raise the dosage, AEDs in general, and Topamax in particular, is so freaking weird that sometimes you need to take 25–50mg a day more to make some of the cognitive side effects go away.

One thing PI sheets and doctors infrequently discuss, and don’t go into enough detail about, is how to discontinue a medication. With some meds it’s not too bad, but with others (most notably SNRIs like Effexor and Cymbalta) it can be a nightmare.

4.  How to stop taking Topamax (topiramate)

Ortho-McNeil now agrees with us. They used to say that you could reduce the dosage by 100mg a day every week as long as you’re taking another anticonvulsant and 50–100mg a day every week no matter what. No more. Per the PI sheet, unless you need to stop taking Topamax due to a severe adverse reaction, you should reduce your dosage by 25–50mg a day every week, and you should be under close supervision.

If the side effects really suck, but aren’t dangerous, you could get away with a 25–50mg reduction every 5 days. Especially if you’re taking another anticonvulsant.

5.  Discontinuation symptoms

---

---

6.  Notes, tips, helpful hints, etc. for discontinuing Topamax (topiramate)

‹ How Long & How Likely To Work, Comparisons with Other Meds | Topamax Index | Pros & Cons, Interesting Stuff Your Doctor Didn’t Tell You ›
Crazy Meds Comprehensive Topamax pages

Bibliography

---

¹ Although not everyone has the luxury of stopping at a dosage when the symptoms abate and not increasing it unless the return. Sometimes you just have to keep going up until you reach that target dosage. E.g. you have a history of seizures that haven't yet responded to several medications.

² Most notably Dr. Edward Faught, founder and Director of the Epilepsy Center, and vice chairman of the Department of Neurology, at the University of Alabama School of Medicine in Birmingham. His article on new antiepileptic drugs in Volume 7 issue 1 of Peer Review in Review stressed starting at low dosages, doing a slow titration, and stopping at the dosage where symptoms were under control. In Topiramate in the treatment of partial and generalized epilepsy*, the one free, full-text article I could find (that's not about geriatric patients), he again stresses the low and slow approach to avoid or lessen most side effects, while still achieving seizure control in the same amount of time.

³ Remember - Pretty much all of the information on this site is for and about adults. You never want to kid 1,000mg of Topamax.

⁴ I think the antipsychotic sundae recipe Mouse and I came up with embarrassed them or something. Both Topamax and Depakote sprinkles are actually pretty tasty. So, too, is lithium citrate syrup. So it just made sense to sprinkle Topamax and Depakote on ice cream and cover it with the orange-flavored lithium citrate syrup. Prozac's oral solution tastes pretty good as well, but it's minty, so you'd probably want to use that on mint-flavored ice cream. It wouldn't work that well on chocolate, as the mint taste is somewhere between schnapps and high-end mouthwash.

⁵ Keep scrolling down, it takes six pages to explain most of Lamictal's commonly used titration schedules. For epilepsy and bipolar disorder.

⁶ Which is why everyone with a functioning brain and half a cup of common sense recommends as slow a titration as possible.

*Link to Topiramate in the treatment of partial and generalized epilepsy Scroll down to the section “Practical use of topiramate”

Date created 11 Jan 2011 - 13:43 Page Creator: Jerod Last edited by: JerodPoore

---

Crazy Meds’ Suggestions on How Much to Take, How to Increase the Dosage, and How to Stop Taking Topamax by Jerod is copyright 2011 Jerod

Page design and explanatory material by Jerod Poore, copyright © 2004 - 2012. All rights reserved.

Almost all of the material on this site is by Jerod Poore and is copyright © 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, and 2012 Jerod Poore. Except, of course, the PI sheets - those are the property of the drug companies who developed the drugs the sheets are about - and any documents that are written by other people which may be posted to this site will remain the property of the original authors. You cannot reproduce this page or any other material on this site outside of the boundaries of fair use copying without the express permission of the copyright holder. That’s usually me, so just ask first. That means if want to print out a few pages to take to your doctor, therapist, counselor, support group, non-understanding family members or something like that - then that’s OK to just do. Go for it! Please. As long as you include this copyright notice and the following disclaimer, I’m usually cool with it.

All rights reserved. No warranty is expressed or implied in this information. Consult one or more doctors and/or pharmacists before taking, or changing how you take any neurological and/or psychiatric medication. Your mileage may vary. What happened to us won’t necessarily happen to you.
The information on Crazy Meds pertains to and is intended for adults. While some information about children and adolescents is occasionally presented (e.g. US FDA approvals), pediatric-specific data such as dosages, side effects, off-label applications, etc. are rarely included in the articles on drugs or discussed on the forum. If you are looking for information regarding meds for children you’ll have to go somewhere else.
Know your sources!
Nobody on this site is a doctor, therapist, or a pharmacist. We don’t portray them either here or on TV. Only doctors can diagnose and treat an illness. Some doctors tend to get pissed off by patients who know too much about medications, so tread lightly when and where appropriate. Diagnosing yourself from a website is like defending yourself in court, you suddenly have a fool for a doctor. Don’t be a cyberchondriac, thinking you have every disease you see a website about, or that you’ll get every side effect from every medication¹. Self-prescribing is as dangerous as buying meds from fraudulent online pharmacies that promise you medications without prescriptions.
All information on this site has been obtained through our personal experience and the experiences family, friends, what people have reported on various reputable sites all over teh intergoogles, the medications’ product information / summary of product characteristic (PI/SPC) sheets, and from sources that are referenced throughout the site. As such the information presented here is not intended as a substitute for real medical advice from your real doctor, just a compliment to it. You should never, ever, replace what a real doctor tells you with something from a website on the Internet. The farthest you should ever take it is getting a second opinion from another real doctor. Educate yourself - always read the PI/SPC sheet or patient information leaflet (PIL) that comes with your medications and never ever throw them away.
Crazy Meds is not responsible for the content of sites we provide links to. We like them, or they’re paid advertisements, or they’re something else we think you should read to help you make an informed decision about a particular med. Sometimes they’re more than one of those things. But what’s on those sites is their business, not ours.
Very little information about visitors to this site is collected or saved. From time to time I look at search terms used and which pages they bring up in an effort to make the information I present more relevant. And the country of origin, just because I’m geeky like that. That’s about it. Depending on how you feel about Schrodinger, our privacy policy should either assuage or exacerbate your paranoia.
All brand names of the drugs listed in this site are the trademarks of the companies named on the PI/SPC sheet associated with the medication, sometimes on the pages about the drugs, even though those companies may have been acquired by other companies who may or may not be listed in this site by the time you read this. Or the rights to the drug were sold to another company. And any or all of the companies involved may have changed their names.
Crazy Meds is optimized for the browser you’re not using on the platform you wish you had. Between you and me, it all looks a lot cleaner using Firefox or Safari, which is what a plurality of visitors use. And I’m running Windows XP3. On a computer that sits on top of my desk. With a 23 inch monitor. Hey, at least you can make the text larger or smaller by clicking on the + or - buttons in the upper right hand corner. If you have Java enabled. Like 99% of the websites on the planet, Crazy Meds is hosted on domain running an open source operating system with a variety of open source applications, including the software used to display what you’ve been reading. As such Crazy Meds is not responsible for whatever weird shit your browser does or does not do when you read this site².
No neurologists, psychiatrists, therapists or pharmacists were harmed in the production of this website. Use only as directed. Void where prohibited. Contains nuts. Certain restrictions may apply. All data are subject to availability. Not available on all mobile devices or in all dimensions of reality.

‘Everything is true, nothing is permitted.’ - Jerod Poore

¹ While there are plenty of books to help you with hypochondria, for some reason there’s not much in the way of websites. Then again, staying off of the Internet is a large part of curing/managing the disorder.

² Have I mentioned how open source operating systems for commercial applications is one of the dumbest ideas in the history of dumb ideas?
[begin rant] I rent a dedicated server for Crazy Meds. It’s sitting on a rack somewhere in Southern California along with a bunch of other servers that other people have rented. The hardware is identical, but no two machines have exactly the same operating systems. I don’t even need to see what is on any of the others to know this. If somebody got their server at the exact same time, with the exact same features as I did, I’m confident that there would be noticeable differences in some aspects of the operating systems. So what does this mean? For one thing it means that no two computers in the same office of a single company have the same operating system, and the techs can spend hours figuring out what the fuck the problem could be based on that alone. It also means that application software like IP board that runs the forum here has to have so many fucking user-configurable bells and whistles that even when I read the manual I can’t find every setting, or every location that every flag needs to be set in order for a feature to run the way I want it to run. And in the real world it means you can get an MBA not only with an emphasis on resource planning, but with an emphasis on using SAP - a piece of software so complex there are now college programs on how to use it. You might think, “But don’t people learn how to use Photoshop or Adobe Illustrator in college?” Sure, in order to create stuff. And in a way you’re creating stuff with SAP. But do you get a Bachelor of Fine Arts degree with an emphasis on Photoshop?
Back in the Big Iron Age the operating systems were proprietary, and every computer that took up an entire room with a raised floor and HVAC system, and had less storage and processing power than an iPhone, had the same operating system as every other one, give or take a release level. But when a company bought application software like SAP, they also got the source code, which was usually documented and written in a way to make it easy to modify the hell out of it. Why? Because accounting principles may be the same the world over, and tax laws the same across each country and state, but no two companies have the same format for their reports, invoices, purchase orders and so forth. Standards existed and were universally ignored. If something went wrong it went wrong the same way for everyone, and was easy to track down. People didn’t need to take a college course to learn how to use a piece of software.
I’m not against the open source concept entirely. Back then all the programmers read the same magazines, so we all had the same homebrew utilities. We even had the forerunner to QR Code to scan the longer source code. Software vendors and computer manufacturers sponsored conventions so we could, among other things, swap recipes for such add-ons and utilities. While those things would make our lives easier, they had nothing to do with critical functions of the operating system. Unless badly implemented they would rarely cause key application software to crash and burn. Whereas today, with open source everything, who the hell knows what could be responsible some part of a system failing. [/end rant]