A 25 year old female has developed migraines following the birth of her first child. She experienced her first migraine about 7 months ago, and has had about 5 more since that time. The migraines are relieved by the use of Sumatriptan, but she is desiring better control.
Her past medical history includes depression for which she is being treated with sertraline. Her only other medication is Ortho-Tri-Cyclen Lo.
She was prescribed topiramate for migraine prophylaxis. Topiramate (Topamax) is notorious for cognitive “slowing” or impairment. This is definitely an adverse effect that we need to watch out for in this case. The other major issue is the topiramate and birth control interaction. Topiramate has the potential to reduce the effectiveness of the estrogen containing birth control, potentially leading to an unplanned pregnancy.
Back up protection should be utilized at a minimum to prevent an unplanned pregnancy. Alternative therapy should also be considered. Valproic acid, amitriptyline, propranolol all certainly have their downsides as well, but would be potential alternatives to avoid the interaction.
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Mental slowing is a very real and fairly common SE of topiramate, earning it the nickname “Dope-a-max” by my pharmacy school classmates that had to discontinue topiramate to keep up with the rigors of pharm school.
Its a carbonic anhydrase inhibitor (kidney stones, etc) and has a funky warning of increased encephalopathy when combined with valproate (which would otherwise be an intuitive combination for seizures or migraine ppx). So watch out for those too.