Butalbital headache occurs when patients are taking medications such as Esgic, Esgic Plus or Fiorcet for treatment of headaches. Some of these also contain caffeine. Chronic use of these pills can actually cause worsening headaches. The most common profile I see is a 50 or 60 year old female who has been taking Fiocet 6-8 pills a day for over 30 years. And yet, somewhere, there is a provider who is giving this person prescriptions.
Each of these brand name medications contain butalbital which is the generic form of the drug. For many years be for the introduction of triptans such as Imitrex, Maxalt and others, most physicians handed out this medication to treat migraine.
Unfortunately, butalbital is a form of opiod and as a result can become addicting if used for a long period of time. In fact, over use became so common in Europe, that the drug is now off the market there.
Now when I say a long period of time, I mean using it for over six months and taking it more than three times per week.
Although not used as commonly as in previous years, generally when we see a patient in their sixties for headache evaluaton, about 75% of them come to us using butalbital too frequently.
Butalbital Headache Symptoms
Butalbital can actually cause migraines to get worse. This happens when the drug is used more and more frequently, which results in transformational migraine. The migraines become more and more frequent and eventually run together to form daily headache.
Image courtesy of Blackwell Synergy from Medscape.com
Note: The left hand side of the graph is pain level and the bottom is time. You can see over time with use of the butabital, the pain levels do not return to zero and that is when you start having daily pain.
With daily use, butalbital headache becomes constant and is usually a lower level headache, perhaps rated a 3 or 4 out of 10 on a pain scale.(This is where 10 is severe disabling pain and you are in bed and perhaps crying.)
The headache may be all over your head and have a throbbing quality.
Treatment of Butalbital Headache
If you have been on this medication for years, treatment depends on how much you are taking daily or weekly. Treated as a form of analgesic rebound headache in our clinic, we tend to use IV infusions of steroids for one or two days to break the cycle of pain. The patient is then on a lower dose of steroid for about a week.
Rarely, we use phenobarbital as a "substitute" medication for a week or two with the steroids. This is used only when we see someone taking multiple daily doses of butalbital. If patients are only using butalbital twice a week or so, Naprosyn 500mg might be substituted for this with sucess.
Caution: Stopping butalbital should NOT be done suddenly as rarely a seizure might result. This type of treatment should be monitored by your physician.
Silberstein, Stephen D. & McCrory, Douglas C. (2001) "Butalbital in the Treatment of Headache: History, Pharmacology, and Efficacy." Headache: The Journal of Head and Face Pain 41 (10), 953-967.
Loder, Elizabeth & Biondi, David (2003) "Oral Phenobarbital Loading: A Safe and Effective Method of Withdrawing Patients With Headache From Butalbital Compounds." Headache: The Journal of Head and Face Pain43(8), 904-909.