Topiramate for Headaches

Topiramate appears to be useful in the prophy-laxis of several types of headache as these case histories illustrate. Patient 1.— A 42-year-old woman presented with recurring headaches since aged 8. She has severe headaches about two times per month described as a generalized throbbing with nausea and occasional vomiting lasting up to 3 or 4 days, but she does not experience aura, or light or noise sensitivity. Triggers have included menses, hunger, alcohol, and smoke. Oral sumatriptan or rizatriptan often help. For the last 25 years, she has had mild, fairly constant, daily headaches which are a generalized or right-or left-sided aching without associated symptoms. She has been taking a few naproxen a week with mild help. A magnetic resonance imaging (MRI) scan of the brain 12 years ago was normal. Over the years, she has been on propranolol and amitriptyline for prevention without benefit. She has tried biofeedback without help, and she exercises three times weekly. She tapered off butalbital with aspirin and caffeine (she was taking about 60 doses per month) on her own 6 months previously, and the headaches became less intense but still daily. Past medical history was negative. She drinks two cups of coffee or less daily. Neurological examination was normal. She is 5 Ј 4 Љ and weighs 210 pounds. The patient was started on topiramate, gradually increasing to 100 mg every 12 hours over 1 month. On follow-up after 1 month, she reported two severe headaches responding well to rizatriptan and two mild headaches responding well to tizanidine, 4 mg. Side effects included a decreased appetite with weight loss of 10 pounds, difficulty concentrating, and tingling of the hands and feet. On follow-up after 4 months, the headaches were even fewer with only one in the prior month responsive to rizatriptan. Her concentration seemed back to normal, but she had lost an additional 5 pounds and still had occasional tingling of the hands and feet. Patient 2.— This 43-year-old woman fell 4 feet off a ladder 3 years prior and hit the back of her head on the floor without loss of consciousness. Ever since, she reported fairly constant, daily, bilateral nuchal-occipital and left more than right pressure without associated symptoms. She was taking two hydrocodone tablets daily, cyclobenzaprine, and etodolac without much help. Physical therapy also did not help. She had no complaints of memory problems, visual symptoms , or dizziness. She …