What are the guidelines for prescribing butalbital (5-allyl-5-isobutylbarbituric acid) for migraine treatment?

Guidelines for Prescribing Butalbital for Migraine

Butalbital-containing medications should be avoided for migraine treatment due to risk of dependence, medication overuse headache, and lack of evidence supporting efficacy.

First-Line Treatment Options

• NSAIDs are recommended as first-line treatment for most patients with migraine 1, 2

  • Aspirin, ibuprofen (400-800mg), naproxen sodium (500mg), and acetaminophen-aspirin-caffeine combinations have the most consistent evidence 1, 2
  • Acetaminophen alone is ineffective 1

• Early treatment during migraine attacks is recommended for optimal efficacy 2

  • Add antiemetics (metoclopramide, domperidone) if nausea/vomiting is present 1, 2

Second-Line Treatment Options

• Triptans should be used when NSAIDs fail 1, 2

  • Options include sumatriptan, naratriptan, rizatriptan, and zolmitriptan 1
  • Triptans are contraindicated in uncontrolled hypertension, basilar or hemiplegic migraine, or patients at risk for heart disease 1

• Consider non-oral routes when nausea or vomiting are significant components 1

  • Intranasal DHE and butorphanol nasal spray have good evidence for efficacy 1

Medications to Avoid

• Butalbital-containing medications should be avoided 1, 2, 3, 4

  • Despite widespread use, butalbital compounds lack placebo-controlled trials for migraine 5
  • Butalbital can cause intoxication, hangover, tolerance, dependence, and toxicity 5
  • Any butalbital use increases the risk of transforming episodic migraine into chronic migraine 4
  • As few as 5 days of butalbital use per month can lead to medication overuse headache 4

• Opioids and ergot alkaloids should also be avoided 1, 2, 3

  • These medications have questionable efficacy and considerable adverse effects 1
  • Risk of dependency is significant 1, 2

Limited Role for Butalbital

If butalbital is ever considered (which should be rare), it should be:

• Used only as a rescue medication when other treatments for severe migraine attacks have failed 1
• Limited to strictly defined appropriate situations 1
• Carefully monitored to prevent overuse 5
• Limited to no more than 2 days per week to avoid medication overuse headache 4

Preventive Treatment Considerations

For patients with frequent migraines (≥2 days/month with significant disability), preventive therapy should be considered 2:

• First-line preventive options:
  • Propranolol (80-240 mg/day)
  • Timolol (20-30 mg/day)
  • Amitriptyline (30-150 mg/day)
  • Divalproex sodium (500-1,500 mg/day)
  • Sodium valproate (800-1,500 mg/day) 1, 2

Monitoring and Follow-up

• Limit acute treatments to 2 or fewer days per week 4
• Monitor for medication overuse headache, which can occur with:
  • 5+ days of butalbital use per month
  • 8+ days of opioid use per month
  • 10+ days of triptan or combination analgesic use per month 4
• Track headache frequency, severity, and medication use with a headache diary 1

Conclusion

The evidence strongly recommends against using butalbital for migraine treatment except in extremely limited circumstances. NSAIDs and triptans have better efficacy data and safer profiles, making them the preferred options for acute migraine treatment.