Topiramate: new indication. Migraine prevention: best avoided

(1) The first-line drug for prevention of migraines is propranolol: it is the most thoroughly evaluated treatment, and thus far no other drug has been found to be more effective. (2) Topiramate, an antiepileptic drug, is now also approved for migraine prevention. Only 3 out of 4 double-blind placebo-controlled trials showed that topiramate 100 mg/day was effective: on average, 46% of patients had a reduction of at least 50% in the frequency of migraines, compared to 23% of patients on placebo. Increasing the dose to 200 mg did not lead to better efficacy. (3) A double-blind trial versus propranolol failed to show that topiramate was as effective or better than propranolol. (4) Topiramate has numerous, frequent and sometimes serious adverse effects, mainly including neurosensory disorders (paraesthesias, language disorders, confusion) and gastrointestinal disturbances. (5) Topiramate treatment costs nearly 5 times more than propranolol. (6) In practice, the adverse effects of topiramate outweigh its efficacy in the prevention of migraine attacks.