What is the recommended dose of butalbital (barbiturate) when combined with acetaminophen (paracetamol) for migraine or tension headache treatment?

Butalbital Dosing for Migraine or Tension Headache

The recommended dose of butalbital when combined with acetaminophen for migraine or tension headache treatment is 50 mg of butalbital with 325 mg of acetaminophen, typically administered every 4 hours as needed, not to exceed 6 tablets per day. 1

Dosing Details and Administration

• Standard formulation contains:

  • Butalbital 50 mg
  • Acetaminophen 325 mg
  • Often includes caffeine 40 mg 1, 2

• Maximum daily limits:

  • No more than 6 tablets in 24 hours
  • Should be limited to no more than twice weekly to prevent medication-overuse headache 3

Place in Treatment Algorithm

1. First-line treatments (start here):

   • NSAIDs (ibuprofen 400-600 mg, naproxen sodium 500-550 mg)
   • Acetaminophen-aspirin-caffeine combinations 3

2. Second-line treatments:

   • Triptans (sumatriptan, rizatriptan, etc.)
   • Dihydroergotamine intranasal spray 3

3. Rescue medications (when others fail):

   • Butalbital-containing compounds
   • Opioids 3

Important Warnings and Precautions

• Risk of medication overuse headache: Butalbital can cause transformation to chronic daily headache when used frequently 4

  • Risk of transformation occurs with as little as 5 days of butalbital use per month 4

• Dependence and withdrawal risk: Butalbital is habit-forming and can lead to addiction 5

  • Withdrawal can cause intractable seizures if stopped abruptly 5
  • For patients using butalbital long-term, it should ideally be weaned slowly over 2 weeks prior to any surgical procedure 5

• Side effects: Common adverse effects include:

  • Drowsiness
  • Light-headedness
  • Dizziness
  • Sedation
  • Nausea and vomiting 5

Recommendations for Use

• Limit use to no more than 2 days per week 4
• Avoid use in patients with a history of substance abuse
• Consider alternative treatments for patients requiring frequent headache medication
• SumaRT/Nap (sumatriptan-naproxen combination) has been shown to be more effective than butalbital-containing medications for multiple efficacy endpoints 1

Perioperative Considerations

For patients undergoing surgery who use butalbital:

• Hold on the day of operation
• For long-term users, wean slowly over 2 weeks prior to surgery
• If unable to wean prior to operation, take preoperatively to avoid withdrawal 5

Butalbital-containing medications should be used cautiously and only when other, safer options have failed. Their potential for causing medication overuse headache and dependence makes them problematic for regular use in headache management.