From the Guidelines
Daily use of Fioricet four times daily for tension headaches is not indicated and should be avoided due to the risk of physical dependence, tolerance, and rebound headaches associated with butalbital, a barbiturate component of Fioricet. According to the American College of Physicians guideline on pharmacologic treatments of acute episodic migraine headache in outpatient settings 1, the use of opioids or butalbital for the treatment of acute episodic migraine is not recommended.
For patients with tension headaches, first-line treatments should focus on non-pharmacological approaches, including:
- Stress management
- Physical therapy
- Regular exercise Combined with as-needed use of simple analgesics like acetaminophen or NSAIDs, considering the appropriate dosage and not exceeding the recommended maximum daily dose 1.
If medication is needed regularly for preventive purposes, options such as amitriptyline, propranolol, or topiramate could be considered. The goal is to address the underlying causes of tension headaches rather than relying on medications like Fioricet that can exacerbate the condition over time. When transitioning patients off daily Fioricet, a gradual taper is recommended to avoid withdrawal symptoms, while simultaneously introducing appropriate preventive therapy.
From the FDA Drug Label
One or two capsules every four hours. Total daily dosage should not exceed 6 capsules. Butalbital, Acetaminophen and Caffeine Capsules, USP are indicated for the relief of the symptom complex of tension (or muscle contraction) headache. The patient's current dosage of Fioricet 4 times daily exceeds the recommended dosage of 1 or 2 capsules every 4 hours and the total daily dosage should not exceed 6 capsules 2. The indication for tension headache is supported by the drug label 2. However, the extended and repeated use of this product is not recommended due to the potential for physical dependence 2. Caution is required when using this combination product for multiple recurrent headaches because butalbital is habit-forming and potentially abusable 2. Given this information, the patient's current dosage regimen of Fioricet 4 times daily is not recommended.
From the Research
Medication Overuse Headache
- Medication overuse headache (MOH) is a subset of chronic daily headache, occurring from overuse of one or more classes of migraine abortive medication 3, 4.
- The main classes of drugs implicated in the genesis of MOH include acetaminophen, combination analgesics (caffeine combinations), opioids, barbiturates (butalbital), non-steroidal anti-inflammatory drugs, and triptans 3, 4.
- Butalbital-containing compounds are widely used for the treatment of migraine and tension-type headache, but their use should be limited and carefully monitored due to concerns about overuse, medication-overuse headache, and withdrawal 5, 6.
Butalbital Use and Medication Overuse Headache
- Butalbital can result in intoxication, hangover, tolerance, dependence, and toxicity, and can produce drug-induced headache in addition to tolerance and dependence 5.
- The recidivism rate is higher after detoxification from butalbital and opioids than after detoxification from other substances 6.
- Adults receiving chiropractic spinal manipulative therapy (SMT) had a significantly lower likelihood of butalbital prescription and medication overuse headache compared to matched controls not receiving SMT 7.
Treatment and Prevention of Medication Overuse Headache
- The treatment of MOH consists of discontinuation of the offending drug(s), acute treatment of the withdrawal symptoms and escalating pain, establishing a preventive treatment when necessary, and the implementation of educational and behavioral programs to prevent recidivism 4.
- Spinal manipulative therapy (SMT) may reduce tension-type headache frequency and intensity, and may be a useful alternative to butalbital prescription 7.