Dr. Ahmed Migraine is common in overweight and obese individuals. The prevalence of migraine in healthy-weight individuals is 3%.
Overweight and obese individuals have a 3 to 5 times greater risk of developing migraine headaches than normal-weight individuals.
Weight loss is one of the desirable goals of all obese and overweight individuals who are also suffering from migraine headaches.
Migraine medications are classified as those which relieve pain and are used as and when needed. These are called abortive medicines.
For individuals having frequent migraine headaches, regular medications are advised to reduce the frequency and severity of the migraines. These are called preventive medicines.
Fortunately, many medications can help prevent and relieve migraines if over-the-counter (OTC) pain relievers are not enough.
Unfortunately, the search for perfect migraine relief can be somewhat of an impossible journey.
While some treatments provide only partial relief, others have unwanted side effects. That is where topiramate comes in.
This is a unique medication that is different from other medicines in that it gives migraine relief and can also help with weight loss.
Here’s a breakdown of the different types of migraine medications:
Over-the-counter pain relievers:
These are the usual first-line treatments for migraines, especially mild or sporadic types.
Painkillers, for example, ibuprofen or acetaminophen, may alleviate pain and lessen inflammation.
However, they may not be the best option for more intense migraines or those accompanied by nausea.
Triptans:
A class of prescription medications formulated for migraines. Triptans act on brain receptors related to migraine pain so as to narrow blood vessels and block pain transmission.
Sumatriptan (Imitrex) and rizatriptan (Maxalt) are examples of triptans. They tend to work better than over-the-counter for moderate to severe migraines.
CGRP antagonists:
CGRP (calcitonin gene-related peptide) antagonists are a newer class of migraine medications.
These medications are highly effective but way too costly. Nurtec (Rimegepant) and Ubrelvy (Ubrogepant) are two well-known brands.
Primarily, these medicines are indicated for the acute treatment of migraine headaches. Nurtec has got FDA approval for migraine prevention too.
Ergots:
Ergotamine (Ergomar) is one of two older drugs prescribed to relieve migraines, the other being caffeine.
Though ergots remain effective in managing cluster headaches, they have been replaced with triptans owing to a side risk of nausea and vomiting, plus interactions with other drugs.
Preventive medications:
These medications are designed to prevent migraines, not to eliminate them, meaning that they would not help get rid of a migraine once it has already started.
They are usually prescribed to be taken daily and may include beta-blockers (used for treating high blood pressure), antidepressants, and anti-seizure medications.
Among these medications, CGRP antagonists are highly effective but very costly. Amitriptyline (Tryptanol) is cheaper and effective, however, it is associated with significant weight gain.
Topiramate (Topamax) is another very effective preventive migraine medicine. It is also the only migraine medicine that is associated with weight loss.
In fact, the Topiramate and Naltrexone combo, available under the brand name Qsymia, is an FDA-approved weight loss medicine.
Topiramate: Diverse Approach to a Challenging Issue
From Epilepsy to Migraines: The Rise of Topiramate
The story of topiramate development as a treatment for migraines is interesting. Developed and first approved in the 1990s for epilepsy, researchers noticed it also seemed to help control migraines.
Research has shown it to be powerful for both the frequency and severity of migraines. Topiramate’s use for migraines has steadily increased, offering relief to many sufferers.
How Topiramate May Combat Migraines
Topiramate’s exact mechanisms of action for migraines are still being investigated. However, several theories exist:
Neurotransmitter Modulation:
- Glutamate is one of the brain chemicals that topiramate may affect. Glutamate is involved in migraine pain pathways.
Stabilizing Brain Activity:
- It might aid in stabilizing irregular electrical activity in the brain, a potential stimulus for migraines.
Inflammation Reduction:
- Topiramate may have anti-inflammatory properties, reducing inflammation that is thought to contribute to migraines.
Exploring Topiramate’s Appetite Control: A Deep Dive into Weight Loss
There has been a lot of interest in topiramate’s potential to help some migraineurs lose weight.
It is FDA-approved for weight loss only in combination with Phentermine as Qsymia.
Let’s delve into the potential mechanisms behind this phenomenon:
Dampening the Appetite Flame:
Brain Chemistry Modulation:
- Topiramate could suppress appetite by modifying the activity of important regions in the hypothalamus [ref].
- This region controls hunger and satiety signals [ref]. Topiramate may inhibit neuropeptide Y (NPY), a potent appetite stimulant, and induce CART (cocaine—and amphetamine-regulated transcript), the peptide that triggers satiety.
Serotonin and Satiety:
- Serotonin creates happiness, or a ‘feel good’ factor, but it also regulates appetite.
- Some studies suggest that topiramate can elevate serotonin concentrations within the brain or potentially enhance serotonin activity within specific brain areas.
- Increased serotonin activity is typically associated with feelings of fullness and a decreased desire to eat.
Individual Variations: Why Weight Loss Is Not Universal
While topiramate can be a weight-loss ally for some, it does not guarantee success for everyone. Here’s why:
Dosage Matters:
- Higher topiramate dosages are frequently linked to significant weight loss. However, higher doses also increase the risk of side effects.
- Doctors carefully calibrate the dosage to balance migraine relief with possible weight loss benefits.
Metabolic Maze:
- Individual differences in metabolism are very important. The body can burn calories more effectively with a faster metabolism, which could enhance topiramate’s weight-loss benefits.
Diet and Exercise Synergy:
- Maintaining a healthy weight requires regular exercise and a good diet.
- Topiramate is helpful, but patients have to get somehow motivated to change their eating habits, and, once again, a balanced diet helps.
The Puzzle of Differential Effects:
There are several complicated reasons why some people who take topiramate lose weight while others do not.
Here are some potential contributors:
Genetic Predisposition:
- A person’s genes can affect how they react to drugs, such as the way topiramate affects metabolism and appetite.
Body Composition:
- Fat burns fewer calories than muscle mass. People who have more muscle mass may lose weight more quickly than people who have a higher body fat percentage.
Underlying Medical Conditions:
- Some medical conditions can influence how the body processes topiramate and its weight-loss effects.
Topamax Dosage for Migraines:
The response to treatment is variable, however, the recommended dosage of Topamax for migraines is as follows:
- Week 1: 25 mg once daily after evening meals
- Week 2: 25 mg twice daily
- Week 3: 25 mg after the morning meal and 50 mg after the evening meal
- Week 4 and thereafter: 50 mg twice daily
Topamax Dosage for Weight Loss:
For weight loss, topiramate is only indicated as Qsymia (a combo drug of Topiramate and Naltrexone).
Qsymia is available in 4 different strengths:
- 3.75 mg Phentermine and 23 mg Topiramate
- 7.5 mg Phentermine and 46 mg Topiramate
- 11.25 mg Phentermine and 69 mg Topiramate
- 15 mg Phentermine and 92 mg Topiramate
The weight loss dosing schedule is:
First two weeks:
- 3.75 mg Phentermine and 23 mg Topiramate (Qsymia 26.75 mg) tablet once daily.
Week 3 to Week 12:
- 7.5 mg Phentermine and 46 mg Topiramate (Qsymia 53.5 mg) tablet once daily.
Week 12 onwards:
- After week 12, if weight loss is less than 3% of the baseline, increase the dose to 11.25 mg Phentermine and 69 mg Topiramate (Qsymia 80.25 mg) tablet once daily for two weeks.
- Increase the dose after two weeks (after 14 weeks total) to 15mg Phentermine and 92 mg Topiramate (Qsymia 107 mg).
If weight loss is less than 5% of the baseline body weight, the treatment needs to be stopped.
