taking, titrating, and tapering Topamax (topiramate)

> How to Take Topamax

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Taking & Titration Overview

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).

Although we often disagree with them, we’ll always give you the manufacturer’s recommendations from Topamax’s full US Prescribing Information. If, for some reason, that isn’t available, we’ll use information for patients leaflets, SPCs from overseas, or whatever official sources we can find. 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.1 As “often” doesn’t mean “always”, whatever is in the PI sheet works for us a lot of the time.

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 dosage2. More and more doctors are agreeing with us3. 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.4

Topamax (topiramate) 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 day5, 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.

Special Instructions/Best Way to Take 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. OrthoMcNeil Janssen Hunger Force (or whatever they’re calling themselves this week) keeps taking those instructions out and putting them back in6.

Topamax (topiramate) Titration (Dosage Increase)


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.

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. Topiramate for Migraine Prevention A Randomized Controlled Trial

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.


It’s complicated, although nowhere near as complicated as Lamictal’s.7 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 DoseEvening Dose
Week 125 mg25 mg
Week 250 mg50 mg
Week 375 mg75 mg
Week 4100 mg100 mg
Week 5150 mg150 mg
Week 6200 mg200 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 Crazymeds suggestion to discuss with your doctor:

 Morning DoseEvening Dose
Week 125 mg25 mg
If your seizures stopped  
Week 225 mg50 mg
Did you have a seizure? No?  
Week 350 mg50 mg
How about this week? Great news!  
Week 450 mg50 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-dependent8, 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.

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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 if not done carefully.

How to Stop Taking Topamax (topiramate)

Ortho-McNeil Janssen Hunger Force 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.

Discontinuation Symptoms

Notes, Tips, Helpful Hints, etc. for Withdrawing Topamax (topiramate)

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  1. Topamax full US Prescribing Information
  2. Faught, Edward. “Topiramate in the treatment of partial and generalized epilepsy.” Neuropsychiatric disease and treatment 3.6 (2007): 811-821.


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

1 And everyone has the time to do their jobs properly, when said time isn't being wasted by idiots asking for grocery store phone numbers** or they aren't playing Angry Farmers on the Faecesbooks.

2 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.

3 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.

4 Assuming you have the luxury of a job, being able to cope with your symptoms not being dealt with for however many days you need to wait in order to do this, and/or someone who can and is willing to stay with you for a few days. Read enough of this site and you can tell what sort of fantasy world I live in.

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

6 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.

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

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

**DrugMonkey, Master of Pharmacy, answers the question “Why your prescription takes so damn long to fill”

If you have any questions not answered here, please see the Crazymeds Topamax discussion board. We welcome criticisms of the articles, notifications of bad links, site problems, consumer experiences with medications, etc. I’m not always able to write back. Hence I never answer questions about meds via e-mail that are answered by this or other articles. Especially if they have been repeatedly asked on the forum. That’s why we write these damn things. Questions about which meds are best for your condition should also be asked on the forum; because this is a free site, so the price of admission is making things easier for somebody else searching for the same answer. We don’t deal with children on the forum or in private because after doing this for ten years I don’t have the emotional stamina to deal with kids who have brain cooties. How to contact Crazymeds. — Jerod Poore, CME, Publisher Crazymeds (crazymeds.us)

Last modified on Sunday, 17 April, 2016 at 18:58:03 by JerodPoorePage Author Date created Tuesday, 11 January 2011 at 13:43:23
“Topamax (topiramate): a Review for the Educated Consumer.” by Jerod Poore is copyright © 2011 Jerod Poore Published online 2011/01/11
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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. If you still have questions about a medication or condition that were not answered on any of the pages you read, please ask them on Crazy Talk: the Crazymeds Forum.
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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 Remember kids, Microsloth operating systems are like TOS Star Trek movies with in that every other one sucks way, way more. With TOS Star Trek movies you don’t want to bother watching the odd-numbered ones. With Microsloth OS you don’t want to buy and install the even-numbered ones. Anyone who remembers ME and Vista knows what I mean.

3 Have I mentioned how open source operating systems for commercial applications is one of the dumbest ideas in the history of dumb ideas?* I don’t even need my big-ass rant any more. Heartbleed has made my case for me. And that’s just the one that got all the media attention. The very nature of an open source operating system makes security as much of an illusion as anonymity on teh Intergoogles. Before you flip out too much: the domain Crazymeds is hosted on uses a version of SSL that is not affected by the Heartbleed bug. That’s one of the many reasons why I pay a lot of money and keep this site on Lunarpages.

* Yes, I know I’m using open source browsers. I also test the site using the now-defunct IE and Safari browsers. Their popularity - and superiority - killed IE and Safari, so that’s why I rely on the open source browsers. It’s like brand vs. generic meds. Sometimes the generic is better than the brand.

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