Medications containing butalbital with either acetaminophen or aspirin, usually with caffeine, are some of the most commonly prescribed medications for the relief of many types of headache and pain relief during Migraine attacks. These medications include Fiorinal®, Fioricet®, Esgic®, Medigesic®, Phrenilin®, and others.
(Note: Ironically, because of the topic of this article, some of the ads near this comment and at the bottom of the page will be for online pharmacies selling butalbital compounds such as Fiorinal and Fioricet with no prior prescription required. Please note that I neither choose nor endorse any advertisement on this site.)
Unfortunately, when used more than two or three days a week, these medications quite often lead to rebound headaches, also referred to as medication overuse headaches.
Rebound headaches present us with additional problems:
- As rebound progresses, we need more of the medications to achieve the same results.
- The rebound headaches will occur until our systems are clear of the medications that caused them.
- To stop rebound, we not only have to stop the specific medications that caused it, but also other medications of the same class of drugs.
- When we're experiencing rebound, preventive medications can't work effectively.
- Some people who withdraw too quickly from butalbital compounds can experience seizures.¹
Dr. Elizabeth Loder and Dr. David Biondi, both noted headache and Migraine specialists, have seen butalbital compound rebound in many patients, and have been looking at ways to withdraw patients from these medications. When patients are taking butalbital compounds daily, it's been a common practice to taper their dose down by one tablet every two to three days. However, if the patient's exact intake isn't reliable established, this method can be ineffective and not entirely safe.
Loder and Biondi undertook a review of 18 cases in which patients were hospitalized for withdrawal from overuse of butalbital medications using a pheonobarbital-loading protocol.
Their objective was "to evaluate the safety and effectiveness of an oral phenobartibal-loading (loading to the patient's level of tolerance) protocol for withdrawal from short-acting, butalbital-combination medications." Phenobarbital has a long half-lifeaveraging 90 hours. This natural slow elimination allows phenobarbital loading, which minimizes the risk of withdrawal seizures from the absence of the butalbital medications. The oral administration is preferred over the intravenous administration that most of us think of in such situations because it allows patients to be more comfortable and reduces opportunities for infection. This method also eliminates the need to account for possibly unknown variable of exactly how much butalbital medications the patient had been taking. In addition to the phenobarbital, the study included a structured program of behavior modification.
Study Patients and Methods:
The 18 patients with headache were inpatients in the Pain Management Program of the Spaulding Rehabilitation Hospital in Boston, Massachusetts. The average length of hospitalization was 23 days, emphasizing withdrawal of the butalbital medications, formulation of both acute and preventive medication regimens, and educating patients about alternative pain-control strategies including ice, heat, biofeedback, hypnosis, meditation, and aerobic exercise. The previously described phenobarbital-loading protocol was used to withdraw the patients from the use of butalbital medications.