Search for articles or Rx savings
Key takeaways
SV2A inhibitors, valproic acid derivatives, carboxamide anticonvulsants, CGRP antagonists, and beta blockers are some alternatives to topiramate for treating seizure disorders and migraine prophylaxis.
Topiramate is used for treating seizures, preventing migraines, and aiding in weight loss, but it may not be suitable for everyone due to potential side effects, cost, and specific patient conditions.
Common reasons for discontinuing topiramate include adverse effects like difficulty with memory, fatigue, and changes in taste, and it may not be appropriate for pregnant women, the elderly, or those with certain health conditions.
Switching from topiramate to an alternative medication should be done under the guidance of a healthcare professional, considering the original indication for use and the patient’s specific health needs.
Topiramate is a prescription medication that was originally brought to market as a medication for seizures. It is now also in medications that help prevent migraine headaches and aid in weight loss. Topiramate is classified as a carbonic anhydrase inhibitor anticonvulsant and is available under several different brand names on the market, including Eprontia, Qudexy XR, Topamax, Topamax Sprinkle, Trokendi XR, and Topiragen. The brand name product, Qsymia, combines phentermine as a prescription weight loss product.
Seizures are uncontrolled electrical events in the brain that may cause changes in behavior, memory, or consciousness. Partial seizures are the most common type of seizures in adults and occur in only one area of the brain’s cortex. General seizures are more diffuse across the cortex. Seizures may be provoked or unprovoked and are difficult to predict.
Approximately 25-30% of first-time seizures are thought to be provoked or brought on by a triggering event such as fever (increased body temperature), brain injuries, sepsis, stroke, or central nervous system (CNS) infections. The term describes the disorder in the brain where abnormal signals cause seizures. In the United States, 2.3 million adults and 450,000 children live with epilepsy. Each year, 150,000 new cases are diagnosed. The exact mechanism by which topiramate helps to control epilepsy isn’t fully understood, but it appears to reduce the duration of the abnormal changes in the brain. Topiramate is approved to treat patients as young as two years of age in some dosage forms for seizures.
While topiramate does not treat a migraine that has already begun, it has a significant role in therapy in terms of preventing migraines, referred to as prophylaxis. It is approved for migraine prophylaxis in adolescents 12 years of age and older. Again, the exact mechanism for how it provides prophylaxis isn’t completely understood.
While topiramate products hold a significant place in therapy for several disorders, there are several reasons why topiramate may not be the best choice for an individual patient. In research done by the manufacturer on epilepsy patients, as many as 20% of patients in some dosing groups discontinued topiramate due to adverse events. These adverse events also affect patients taking topiramate for migraines. The most common side effects that lead to discontinuation included difficulty with memory, fatigue, asthenia, insomnia, somnolence, and paresthesia. Some patients also report a change in the way foods taste. For some patients, these adverse events manifest in different ways. For instance, some may have difficulty coming up with specific words as they are speaking or remembering something that just happened. These serious side effects of topiramate use can be concerning to them or those around them.
Some forms of topiramate can be very expensive and cost prohibitive. The cost of Trokendi XR can approach $1200 per month before insurance, and coverage of the drug is very much dependent upon the plan. However, generic topiramate immediate-release tablets are less than $3 per month without insurance with the use of a SingleCare coupon. Many plans may require you to try the generic immediate-release form before they authorize coverage of a more expensive form of topiramate.
In other populations, topiramate in all or certain dosage forms may not be the best choice for patients. Those with an allergy to topiramate should look for alternative therapy. Trokendi CR cannot be taken within 6 hours of ethanol ingestion or if there has been ethanol intoxication. Topiramate is generally not appropriate in elderly patients or those with decreasing renal function. Stevens-Johnson syndrome (SJS) has been reported with topiramate treatment, and it should be discontinued immediately if this occurs. Topiramate can not be taken during pregnancy.
Topiramate and most seizure medications carry a warning for patients who have a history of depression or suicidal thoughts, as this class of medications could worsen this effect. This could be especially true in pediatric patients; all patients should be monitored closely. If there are signs or symptoms of these thoughts, patients should seek medical help immediately.
So what do you do if you think topiramate isn’t right for you? Perhaps you are looking for an option with fewer side effects. Below, we will discuss some alternative options you may have depending on what you are using topiramate for.
What can I take in place of topiramate?
There are alternative treatment options to topiramate, but choosing the right alternative will need to take into account several factors. First, the decision to change therapy is one that you should only make with your healthcare professional. The options available to you will depend upon the original indication of why you were taking topiramate in the first place. If you were taking it for seizure disorders, there is a list of viable alternative medication options. If you were taking it for migraine prophylaxis, there are actually a lot of new medications in that field, as well as older, proven medications to choose from. The indication for use and the reason for change will be the primary determining factors for your next best medication therapy option.
Below is a list of available alternatives for topiramate treatment in seizure disorder and migraine prophylaxis. This is not a complete list; only your doctor can decide what is appropriate for you. Some drugs used are done off-label or without approval from the FDA. Beta-blockers and tricyclic antidepressants in the prevention of migraines are examples of this.
Compare Topamax (topiramate) alternatives |
|||
|---|---|---|---|
| Drug name | Uses | Dosage | Savings options |
| Topamax (topiramate) | Monotherapy or adjunct therapy for partial or generalized tonic-clonic seizures, adjunct treatment of Lennox-Gastaut syndrome, migraine prophylaxis | 100 mg to 200 mg by mouth twice daily | Topamax coupons |
| Keppra (levetiracetam) | Treatment of partial seizures, adjunct treatment of myoclonic seizures, adjunct treatment of generalized tonic-clonic seizures | 1,500 mg by mouth twice daily | Keppra coupons |
| Tegretol (carbamazepine) | Treatment of generalized tonic-clonic seizures, partial seizures | 400 mg by mouth four times daily | Tegretol coupons |
| Depakote (divalproex sodium) | Monotherapy or adjunct treatment of absence seizures, complex partial seizures, tonic-clonic seizures, myoclonic seizures, acute mania with bipolar disorder, migraine prophylaxis | 15 to 60 mg/kg/day in at least 2 divided doses | Depakote coupons |
| ONFI (clobazam) | Adjunct treatment of Lennox-Gastaut syndrome | 20 mg by mouth twice daily | ONFI coupons |
| Vimpat (lacosamide) | Monotherapy and adjunct treatment of partial seizures, adjunct treatment of generalized tonic-clonic seizures | 150 mg to 200 mg by mouth twice daily | Vimpat coupons |
| Neurontin (gabapentin) | Adjunct treatment of partial seizures with or without secondary generalized tonic-clonic seizures | 300 mg to 600 mg by mouth three times per day | Neurontin coupons |
| Lyrica (pregabalin) | Neuropathic pain, adjunct treatment of partial seizures, fibromyalgia | 50 mg by mouth three times per day | Lyrica coupons |
| Dilantin (phenytoin) | Treatment of tonic-clonic seizures, treatment of status epilepticus | 4 to 7 mg/kg/day by mouth in one, two, or three doses per day, depending on the dosage form | Dilantin coupons |
| Emgality (galcanezumab) | Migraine prophylaxis, treatment of episodic cluster headache | 240 mg subcutaneously as a loading dose, followed by 120 mg subcutaneously once monthly | Emgality coupons |
| Inderal LA (propranolol ER) | Chronic stable angina, atrial fibrillation/ flutter, paroxysmal supraventricular tachycardia (PSVT), hypertension, reduction of mortality after myocardial infarction, migraine prophylaxis | 60 mg to 240 mg by mouth once daily | Inderal LA coupons |
| Nurtec ODT (rimegepant) | Acute treatment of migraine with or without aura, episodic migraine prophylaxis | 75 mg by mouth every other day | Nurtec ODT coupons |
| Verelan (verapamil) | Treatment of variant angina and chronic stable angina, rapid conversion of PSVT, atrial fibrillation/ flutter, hypertension, migraine prophylaxis | 80 mg by mouth three to four times per day (**use is off-label) | Verelan coupons |
| Aimovig (erenumab) | Migraine prophylaxis | 70 mg or 140 mg subcutaneously once monthly | Aimovig coupons |
| Tenormin (atenolol) | Angina pectoris, hypertension, reduction of mortality after myocardial infarction, migraine prophylaxis | 100 mg by mouth once daily (**use is off-label) | Tenormin coupons |
| Ajovy (fremanezumab) | Migraine prophylaxis | 225 mg subcutaneously once monthly or 675 mg subcutaneously every 3 months | Ajovy coupons |
Other alternatives to topiramate
- Lamictal (lamotrigine)
- Keppra XR (levetiracetam ER)
- Tegretol XR (carbamazepine)
- Trileptal (oxcarbazepine)
- Fycompa (perampanel)
- Briviact (brivaracetam)
- Aptiom (eslicarbazepine)
- Oxtellar XR (oxcarbazepine)
- Elavil (amitriptyline)
- Botox (onabotulinumtoxinA)
- Corgard (nadolol)
- Procardia (nifedipine)
Top 5 topiramate alternatives
The following are some of the most common alternatives to topiramate.
1. SV2A Inhibitors
SV2A inhibitors are a group of antiepileptic drugs used to treat partial seizures and as adjunctive treatment in myoclonic seizures and tonic-clonic seizures. The advantages of this group of drugs include minimal interactions with other classes of antiepileptic drugs and minimal adverse effects. There are dosages available for children as young as one month of age. SV2A inhibitors have no indication for usage in migraine treatment or prophylaxis.
Examples: Keppra (levetiracetam), Spritam (levetiracetam), Briviact (brivaracetam)
2. Valproic Acid Derivatives
Valproic acid derivatives are indicated as monotherapy or adjunct therapy in simple or complex absence seizures, complex partial seizures, and as adjunct therapy in tonic-clonic seizures and myoclonic seizures. Dosing options aren’t approved in age groups as young as SV2A inhibitors, though they are sometimes used off-label in groups as young as the neonatal stage of life. Depakote and Depakote ER are also approved for migraine prophylaxis and are among the few drugs to similarly carry both major indications of topiramate. Nausea and abdominal pain are some of this drug class’s most frequent side effects. These drugs should not be used in patients with kidney problems or liver problems, nor should they be used in pregnant women. They have been linked to congenital birth defects such as cleft lip and cleft palate.
The prescriber and patient are responsible for ensuring the female patient is adequately protected from pregnancy while taking this medication. Regular blood tests to confirm may be necessary. This class of drugs has been available for quite some time and is a good option if you are looking for an affordable generic drug.
Examples: Depakote (divalproex sodium), Depakote ER (divalproex sodium), Depakene (valproic acid),
3. Carboxamide Anticonvulsants
Carboxamide anticonvulsants are another alternative to topiramate for treating epilepsy, specifically tonic-clonic seizures, and either simple or complex partial seizures. Weight-based dosing for children younger than 6 is approved for seizures. While this class is used sometimes in neuropathic pain disorders, it is not approved for use in migraine disorders. This class of anticonvulsants has been linked to the serious, life-threatening reaction known as Stevens-Johnson syndrome. This starts as flu-like symptoms and quickly evolves to include a painful rash that spreads and blisters. It damages the mucous membranes and skin, and wound care is complex. People should be warned of the signs and symptoms before beginning this class of medications and must seek medical care at the first sign of a rash.
Examples: Aptiom (eslicarbazepine), Tegretol (carbamazepine), Trileptal (oxcarbazepine), Oxtellar XR (oxcarbazepine)
4. Calcitonin Gene-related Peptide (CGRP) Antagonists
CGRP antagonists are monoclonal antibodies and do not have a role in seizure treatment but do play a role in migraine prophylaxis and even the treatment of chronic migraine attacks. CGRP receptors are distributed throughout the nervous system, and we know there is a concentration in the trigeminovascular system where migraine pathophysiology appears to be centered. Inhibition of these receptors plays a role in vasodilation and pain modulation. Not every drug in the class is approved for migraine prophylaxis or prevention.
Whether or not CGRP antagonist treatment is right for you may depend on your migraine frequency, or how often you suffer from migraines. Some are only approved for prevention or treatment, but not both. Most drugs in this class are injectables, except Nurtec ODT, which is an important factor to consider.
This class of drugs has not been studied adequately in pregnant women, and therefore their safety is not known. All drugs in this class are available on the market as brand-name products only and may be cost-prohibitive to some without insurance coverage or cost savings from the manufacturers.
Examples: Aimovig (erenumab), AJOVY (fremanezumab), Emgality (galcanezumab), Nurtec ODT (rimegepant)
5. Beta Blockers
Beta-blockers have been used off-label for quite some time for migraine prophylaxis in adults. Off-label indicates widely accepted use without official approval for the indication from the Food and Drug Administration (FDA). Beta-blockers have numerous mechanisms that may make them useful in migraine prophylaxis, including arterial dilation and renin secretion inhibition. Beta-blockers have historically been used to treat blood pressure and cardiac disorders. The drugs may inadvertently lower the blood pressure of someone taking them for migraine prophylaxis, and this should be monitored. Beta-blockers are not useful in seizure disorder treatment.
Examples: Tenormin (atenolol), Corgard (nadolol), Inderal (propranolol)
Natural alternatives to topiramate
With regard to the treatment of epilepsy or seizure disorder, many alternative treatments have been mentioned in different cultures and parts of the world. Some parts of the world see natural medicine as a complement to traditional Western medication options, while others seek to replace traditional Western medications with natural or holistic treatments. Products such as black cohosh and caffeine have been evaluated for their effect on epilepsy, however, finding placebo-controlled trials of natural medications in seizures is very difficult. Ultimately, there is just very little evidence that these options provide any benefit to epilepsy patients at this point.
There is a general agreement that maintaining good health, a healthy weight and exercise regimen, and getting the recommended daily allowance of key vitamins is good for all patients, especially those who suffer from seizures or migraines. Some products may have interactions with your medications, however, so make sure to check your products with your doctor or pharmacist to be sure they are safe to take with your prescribed medications.
Cognitive behavioral therapy may also benefit many patients with both seizures and migraines. Your doctor can help you determine if this is an option for you.
How to switch to a topiramate (Topamax) alternative
You should never stop taking topiramate without speaking to your healthcare provider first. We have provided some alternatives to topiramate for its two most common uses that you may want to discuss with your doctor if you feel your topiramate medication isn’t the best choice. This isn’t meant to be medical advice, but simply talking points to speak with your prescriber on.
If cost is your primary concern, your insurance company or local pharmacist may be able to provide more information on your formulary, or an approved list of drugs on your plan. Before you head to the pharmacy, you can check out the free SingleCare prescription coupon hub to find the lowest cash price available to you in your area for your prescription.