Is it safe to take Topamax during pregnancy?

Topamax (topiramate) is one of the most commonly prescribed medications for treating epilepsy, seizure disorders, and migraine headache prevention. This medication works along neurological pathways to normalize brain cell activity and reduce brain overactivity, reducing the amount and severity of seizures. The mechanism to prevent migraine is not exactly known.

The main use of Topamax is for seizures, but it also has a few off-label medical uses for conditions such as antipsychotic-induced weight gain, binge eating disorder, cluster headache prevention, and more. This makes the conversation around whether or not it’s safe to take during pregnancy especially relevant. While the number of expectant mothers with seizure disorders is relatively small, the number of pregnant women who could potentially be prescribed topiramate grows once you factor in other treated medical conditions.

“Topamax is primarily used as an anti-epileptic, but it is also used for migraines, pain conditions, and weight loss,” says Jennifer Payne, MD, associate professor of psychiatry and behavioral sciences and director of the Women’s Mood Disorders Center at Johns Hopkins Medicine.

Less frequently, Topamax is used to treat patients with bipolar disorder, anxiety, depression, and PTSD, though there is debate among experts about the underwhelming lack of evidence regarding Topamax’s effectiveness in improving mental health conditions. 

Whatever your reasons may be for discussing the use of Topamax during your pregnancy, there are important health concerns to be aware of before beginning or continuing to use this drug while expecting a baby. Here’s what you need to know.

Is it safe to take Topamax while pregnant? 

Topiramate is a pregnancy category D drug, which means there are known risks associated with taking it while pregnant with some data showing it crosses the placenta and could be detected in newborn’s blood. There may still be medically  necessary reasons to do so, but it must be discussed carefully with your doctor so that you can weigh the pros and cons together.

“Though not widely studied, the current data demonstrate an increased rate of major congenital malformations, specifically cleft palate, and an association with [babies born] small for their gestational age and with low birth weights,” Dr. Payne says.

A few studies have observed the risk of Topamax birth defects; one from 2017 published in the American Journal of Obstetrics and Gynecology, for example, showed an increased risk of cleft palate in babies exposed to topiramate during the first trimester.

What’s more, the risk may grow even higher depending on the reason why an expectant mother is taking Topamax: in a 2018 study published by Neurology, the potential for oral clefts of the lip and/or palate was higher in expectant mothers taking Topamax for epilepsy as opposed to other conditions. Study researchers think this may be because the dosage of Topamax for epilepsy is often much higher than it is for conditions like migraine.

RELATED: Topamax side effects and how to avoid them

Can Topamax affect fertility? 

Even if you aren’t currently pregnant or planning to become pregnant, if you’re a woman of childbearing age, it is important to discuss fertility, contraception, and future pregnancy with your provider if you are taking Topamax. Also, there are a few things you should know about taking Topamax. 

1. Topamax can make hormonal birth control containing estrogen or progesterone less effective, says Dr. Payne, so this may cause reduced contraceptive effectiveness. Dr. Payne also suggests waiting a few weeks after discontinuing Topamax before trying to get pregnant to make sure the drug has fully cleared from your system.
2. As of right now, there is no evidence that taking Topamax directly affects male or female fertility. But some data suggests that seizure disorders and prolonged use of seizure medication can make it harder to achieve a pregnancy; men taking anti-epilepsy drugs may end up with abnormal sperm, and women taking these drugs may experience abnormal menstruation and ovulation. These findings haven’t been conclusively proven, however.
3. No studies have been done to see if there is an increased risk of miscarriage for women taking Topamax before or during pregnancy. But there doesn’t seem to be any evidence, as of now, that Topamax is associated with a higher incidence of miscarriage.

What should you do if you become pregnant while taking Topamax?

Many medications will cause withdrawal symptoms if you stop taking them abruptly and this is also true for Topamax; any kind of “cold turkey” approach to stopping its use can cause physical illness and other dangerous symptoms.

Instead of stopping Topamax abruptly, talk to your healthcare provider about weaning off quickly but safely. Depending on your dosage, you may be able to stop taking it completely within two to three weeks (though it may take longer if your dose is very high).

Overall, unless you absolutely need to stay on Topamax during pregnancy, it’s best to discontinue use under your physician’s supervision, says Dr. Payne—and ideally, you should make a plan for utilizing alternative medications before becoming pregnant, whenever possible.

Is there any safe amount of Topamax during the trimesters of pregnancy?

Use of Topamax isn’t advised during any part of pregnancy—but especially during the first trimester due to the instances of birth defects involving the facial area, according to Kecia Gaither, MD, OB-GYN and maternal fetal medicine specialist, director of perinatal services at NYC Health + Hospitals/Lincoln.

“Topamax may also increase the incidence of hemorrhagic disease in the newborn by depleting fetal vitamin K stores,” Dr. Gaither adds. Vitamin K is responsible for forming blood clots and preventing excessive bleeding; ongoing deficiency in infants can be life-threatening.

Beyond the first trimester, use of topiramate isn’t likely to result in birth defects, but instead in adverse birth outcomes. Second and third trimester use of the drug may cause babies to be born small for their gestational age, as Dr. Payne previously noted.

If you need to be on Topamax during pregnancy, your provider  will determine the safest dose for you and your baby. If possible, it’s best to discuss this before you plan on getting pregnant. In general, higher doses—like the ones used to treat epilepsy—are more often associated with increased risks to your baby; according to the MGH Center for Women’s Mental Health, doses higher than 100 milligrams should be avoided, if possible.

Is Topamax safe while breastfeeding?

The short answer? Physicians can’t say for certain. According to Dr. Gaither, topiramate does cross the placenta and is excreted in breast milk. Unfortunately, it’s unknown how much is excreted. Many experts, though, don’t estimate the amount to be high enough to pose a serious risk to the baby. Overall, the patient and provider should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and benefits of treatment to the mother. There is a risk of diarrhea and sleepiness in breastfed infants, which may impact overall feeding.

“There are no long-term studies, but it’s generally considered low-risk,” Dr. Payne says.

She suggests patients turn to LactMed for advice on what to keep in mind, which includes monitoring babies (particularly very young, exclusively breastfed ones) for diarrhea, excessive sleepiness, adequate weight gain, and psychomotor development.

Which anticonvulsants are safe to take while pregnant and nursing? 

Though no medication is ever considered 100% safe during pregnancy, many of these drugs pose less of a risk to expectant mothers than the risk of not being on a medication. Those with seizure disorders may experience more seizures during pregnancy. The kidneys clear anti-seizure medications from your body more quickly during pregnancy. As much as possible, women with any medical conditions should consult their provider before getting pregnant to plan for a safe and healthy pregnancy.

If medication during pregnancy is necessary, monitoring medication levels is important at the start of each trimester and during the last month of pregnancy. Lamotrigine and levetiracetam are the most commonly used anticonvulsants during pregnancy, according to the Epilepsy Foundation. Consult with your healthcare provider about what is the best option for you.