TOPAMAX - Adverse Event - Alopecia

SUMMARY

• Alopecia has been reported during clinical trials.¹
• Three published case reports reported alopecia associated with adjunctive topiramate therapy, including one case without rechallenge and two cases with a positive rechallenge.^2-4

PRODUCT LABELING

As described in the ADVERSE REACTIONS section of the Full Prescribing Information¹:

In the monotherapy epilepsy trial, alopecia was reported in 1% and 4% of pediatric patients (6 to <16 years of age) receiving topiramate 50 mg/day and 400 mg/day, respectively. Alopecia was reported in 3% and 4% of adult patients (≥ 16 years of age) receiving topiramate 50 mg/day and 400 mg/day, respectively.

CLINICAL DATA

There is limited information from published literature regarding the occurrence of alopecia during treatment with topiramate. The duration and severity of this adverse event cannot be predicted for individual patients.

Case Reports

Unler et al (2025)² described the case of a 25-year-old female patient with myoclonic epilepsy and unspecified anxiety disorder who presented with nervousness, restlessness, constant anxiety, palpitations, and shortness of breath. Multiple dosing regimens were initiated, including escitalopram 10 mg/day, followed by sertraline 50 mg/day (subsequently increased to 75 mg/day), valproic acid 1000 mg/day, and levetiracetam 1000 mg twice daily (subsequently increased to 3000 mg/day). As the patient had experienced excessive weight gain and her seizures were under control, topiramate 25 mg twice daily was introduced without discontinuing the existing antiepileptic medications.

One month after topiramate initiation, the patient's anxiety symptoms had completely resolved, and she had not experienced any seizures. At this time, she reported diffuse, nonscarring hair loss, particularly at the vertex, which had been ongoing for 2 weeks. The patient had no history of significant hair loss associated with antiepileptic drugs and was not pregnant when topiramate was initiated. There was no history of dermatitis, weight loss, endocrine disorders, or autoimmune disease. Laboratory investigations, including thyroid function tests, serum biochemistry, hemogram, β-human chorionic gonadotropin (β-hCG), serum ferritin, folic acid, and vitamins B12 and D, were within normal limits. Dermatologic evaluation did not identify an alternative cause of hair loss. The pull test was positive and revealed normal club hairs. No changes in hair texture, including curling, graying, or a dirty appearance, were reported.

Topiramate was discontinued because of suspected drug-related hair loss. Hair shedding subsequently stopped, and regrowth was observed within 2 weeks while the patient remained seizure-free. A Naranjo Adverse Drug Reaction Probability Scale score of 6 indicated a probable adverse drug reaction. The patient was evaluated monthly for 6 months, during which no additional cosmetic adverse effects were reported, and she remained seizure-free for 8 months. By February 2024, as anxiety symptoms were in remission, sertraline was gradually discontinued, and the patient was maintained on levetiracetam 3000 mg/day and valproic acid 750 mg/day.

Lagrand et al (2021)³ described a case report of a 56-year-old female patient who developed alopecia areata after treatment with three medication regimens: levodopa/benserazide, propranolol, and topiramate. The patient was initiated on levodopa 100 mg /benserazide 25 mg for tremors associated with Parkinson’s disease and developed alopecia. No underlying auto-immune disease was detected. Discontinuation of medication and treatment with topical steroids, a calcineurin inhibitor and minoxidil resulted with hair regrowth after 3 months. The patient was initiated on propranolol 40 mg after experiencing worsening tremors and hair loss was again observed. After discontinuation of propranolol, regrowth of hair was observed in a few weeks. Treatment with primidone 125 mg was undertaken but discontinued due to cognitive dysfunction and hallucinations. One year later, topiramate 50 mg/day was initiated due to tremors extending to her left leg. First signs of hair loss were observed in less than 2 weeks, and discontinuation of the medication resulted in hair regrowth after a few weeks.

Chuang et al (2002)⁴ described a case of a 15-year-old female patient who developed alopecia while on adjunctive topiramate therapy for epilepsy.⁴ The patient was initiated on carbamazepine and vigabatrin for frontal lobe epilepsy. Upon experiencing inadequate seizure control, vigabatrin was replaced with topiramate, titrated up to a dose of 200 mg/day. Two months after topiramate was added, the patient developed partial diffuse nonscarring hair loss over the frontal scalp. The color and texture of the hair was not altered and there was no family history of alopecia. Topiramate was discontinued at this point and new hair growth gradually resumed. The patient was re-initiated on topiramate when breakthrough seizures occurred. A month after adjunctive topiramate therapy was restarted, the patient experienced hair loss again. The authors concluded that alopecia was a possible adverse event since it reoccurred when the patient was re-challenged with topiramate.

Literature Search

A literature search of MEDLINE^®, Embase^®, BIOSIS Previews^®, and Derwent Drug File (and/or other resources, including internal/external databases) pertaining to this topic was conducted on 20 July 2026.