medication for alcoholism to reduce cravings

Topiramate (Topamax) for Alcohol Use Disorder

Medically reviewed by Dr. Paul R. Linde, MD on March 2, 2023

Topiramate (sometimes sold as Topamax) is a medication usually prescribed to treat seizures and migraines, which also seems to help with alcohol use disorder (AUD). People who take it appear to have fewer cravings. They also report less pleasure from alcohol, and have fewer anxiety-related drinking urges. Topiramate has shown strong all-around effectiveness in clinical trials, and is available generically.

As an AUD treatment, topiramate is best for:

  • Limiting alcohol cravings
  • Improving anxiety-related drinking
  • Reducing overall consumption
  • Treating physical addiction symptoms

Is it right for you? Skip to pros and cons

Medically reviewed by Dr. Paul R. Linde, MD on March 2, 2023

Table of Contents

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How Does Topiramate Work?

Research is ongoing, but topiramate appears to work by altering one’s brain chemistry in a way that reduces alcohol cravings short-term.1 It also reduces alcohol withdrawal symptoms, and can make it easier to stick with change during the first several months.

Here is one explanation for why topiramate works to reduce drinking:

  • Alcohol consumption affects numerous brain chemicals, including two called glutamate and GABA.
  • Glutamate is an excitatory brain chemical. Alcohol suppresses it, which slows brain activity while you drink.2  
  • GABA is a calming agent that reins in your nervous system activity. Alcohol affects your GABA receptors, making you feel relaxed.3  
  • The body compensates for chronic, heavy drinking by reducing GABA, and increasing glutamate. This makes your nervous system more active at baseline, influencing withdrawal symptoms and cravings.
  • Topiramate seems to counteract this imbalance, blocking the activity of two subtypes of glutamate receptors while enhancing the action of GABA. This leads to less anxiety when you don’t drink, making it easier to say no to alcohol.

Overall, the effects of Topamax on alcohol consumption have similarities to both naltrexone and acamprosate. Like acamprosate, topiramate can reduce cravings and make it easier to stick with abstinence. Like naltrexone, it can also be effective in helping someone cut back when they are still drinking. In other words, topiramate can be a good all-around medication for alcohol use disorder.

The Evidence For Topiramate

Although topiramate is not specifically FDA-approved for alcohol use disorder, there is plenty of evidence to support its use.

In a 2011 review of studies by University of Virginia, researchers concluded that “there is now solid clinical evidence to support the efficacy of topiramate for the treatment of alcohol dependence.”4 And more studies since then have confirmed the drug’s usefulness in reducing heavy drinking.5

In one key study, even low doses of topiramate were effective in reducing anxiety and depression symptoms, as well as cravings, during alcohol withdrawal. It also helped participants abstain from drinking during the first 16-week detoxification period.6 Topamax even seems to work better than naltrexone in some cases.7

If topiramate is so effective, why isn’t it better-known?

To date, the FDA has only approved topiramate for seizure and migraine treatment. This means that, for AUD, it is considered an “off-label” medication (a drug approved for one purpose, but prescribed for another because a doctor deems it safe and useful).

This does not mean that topiramate is unsafe. In fact, one of the primary reasons it is not specifically approved for AUD is that the pharmaceutical industry has little financial incentive to apply for that approval. However, as an off-label medication, topiramate remains a second-line treatment, behind better-known therapies like naltrexone, disulfiram, and acamprosate. It is often started after naltrexone and/or gabapentin is ineffective in helping people stop or reduce their drinking.

Side Effects of Topiramate

Topiramate is usually well-tolerated. In order to reduce the risk of any adverse effects, however, it is best to slowly increase the dosage over several weeks. Topiramate’s main side effects include:

  • Dizziness    
  • Numbness or tingling
  • Memory impairment    
  • Fatigue
  • Weight loss   
  • Concentration issues
  • Very small but possible risk of kidney stones or increased eye pressure
  • Missed period or excessive bleeding8

These effects are typically mild and last for a short time. Canada’s Centre for Addiction and Mental Health, however, notes that nearly 20 percent of its patients stop using topiramate due to side effects.9

Topiramate is not habit-forming and does not cause individuals to become psychologically or physically dependent. Like with acamprosate and gabapentin, people on topiramate should be monitored for suicidal behavior, which is rare, but serious. Kidney stones and increased ammonia production have been reported, so people with kidney issues should exercise caution.

Finally, topiramate may interfere with some oral contraceptives, and has shown the ability to cause birth deformities. Women of reproductive age should discuss their plans with their doctor before taking topiramate.

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Is Topiramate For You?

Topiramate May Be Helpful If:

  • You want to reduce how much you drink
  • You struggle with cravings and physical addiction symptoms

Topiramate May Not Be Best If:

  • You are pregnant
  • You have kidney disease or a tendency to develop kidney stones
  • You have a history of depression

Although topiramate is not specifically FDA-approved to reduce drinking, it appears to be very effective and safe for this purpose. Because it helps reduce both alcohol cravings and the pleasurable effects of drinking, it can be a good stand-in for naltrexone. Because it helps rebalance your brain chemistry, topiramate can also be a good substitute for acamprosate or gabapentin. In fact, overall, this medication can do a little bit of everything. 

Side effects of Topamax can be more troublesome than with some other options, but they are usually manageable. As a result, topiramate is one of the better off-label choices for fighting alcohol addiction. If you’ve had trouble with any of the other approved medications, this option may work for you.

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