What is the preferred treatment approach for a patient with migraines and tension headaches using Ubrelvy (ubrogepant) and Fiorcet (butalbital, acetaminophen, and caffeine)?

Preferred Treatment Approach for Migraines and Tension Headaches

Discontinue Fioricet immediately and transition to Ubrelvy as your primary acute migraine treatment, limiting use to no more than 2 days per week to prevent medication-overuse headache. 1, 2

Why Fioricet Must Be Discontinued

• Butalbital-containing compounds like Fioricet are flagged as rescue medications only because they lead to medication-overuse headache, rebound headaches, tolerance, dependence, and eventual loss of efficacy when used regularly. 1, 2, 3

• The American College of Physicians explicitly recommends avoiding butalbital compounds when used more than twice weekly, as they create a vicious cycle of daily headaches through medication overuse. 1, 2

• Fioricet is FDA-approved only for tension-type headache, not migraine, and evidence supporting its use for multiple recurrent headaches is unavailable. 4

• Butalbital can produce intoxication clinically indistinguishable from alcohol, along with hangover, tolerance, and withdrawal syndromes after discontinuation. 3

Why Ubrelvy Is the Superior Choice

• Ubrelvy (ubrogepant) is a CGRP receptor antagonist specifically indicated for acute migraine treatment with demonstrated efficacy: 21.8% of patients achieved pain freedom at 2 hours (vs 14.3% placebo), and 38.9% achieved freedom from most bothersome symptom at 2 hours (vs 27.4% placebo). 5

• Ubrelvy significantly improved functional disability, with 40.6% of patients able to function normally at 2 hours compared to 32.0% with placebo. 6

• The safety profile is favorable, with the most common adverse events being nausea (2.0%) and dizziness (1.4%), comparable to placebo rates. 5

• Unlike butalbital, Ubrelvy does not carry risks of dependence, rebound headache, or medication-overuse headache when used appropriately. 7

Critical Frequency Limitation

• Restrict Ubrelvy use to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1

• If you require acute treatment more than twice weekly, you need preventive therapy rather than escalating acute medication use. 1, 2

Dosing Strategy for Ubrelvy

• Start with Ubrelvy 50 mg at migraine onset when pain is still mild to moderate for optimal efficacy. 8, 5

• A second dose may be taken if headache returns or does not respond, but only between 2-48 hours after initial dose. 8

• The 100 mg dose showed similar efficacy to 50 mg (21.2% vs 19.2% pain freedom at 2 hours) but is available if 50 mg proves insufficient. 1

Drug Interaction Cautions with Ubrelvy

• Avoid strong CYP3A4 inhibitors (like ketoconazole), which increase ubrogepant exposure 9.7-fold. 8

• Use caution with moderate CYP3A4 inhibitors (like verapamil), which increase exposure 3.5-fold. 8

• Avoid strong CYP3A4 inducers (like rifampin), which reduce ubrogepant exposure by 80%. 8

• Ubrelvy has no significant interactions with common migraine medications including NSAIDs (naproxen), acetaminophen, triptans (sumatriptan), or CGRP monoclonal antibodies. 8

When Preventive Therapy Is Indicated

• Initiate preventive therapy if you have:

  • Two or more migraine attacks per month producing disability lasting 3+ days 1
  • Need for acute medication more than twice weekly 1, 2
  • Failure of acute treatments despite optimization 1

• First-line preventive options include propranolol 80-240 mg/day, timolol 20-30 mg/day, topiramate, or divalproex sodium. 1

Backup Strategy for Tension Headaches

• For pure tension-type headaches (not migraine), use naproxen sodium 500-825 mg as first-line treatment, limited to 3 consecutive days and no more than twice weekly overall. 1

• Combination therapy with aspirin 500 mg + acetaminophen 500 mg + caffeine 130 mg is effective for moderate tension headaches when NSAIDs alone are insufficient. 1, 9

Common Pitfall to Avoid

• Do not allow yourself to increase frequency of acute medication use in response to treatment failure. This creates medication-overuse headache. Instead, transition to preventive therapy while optimizing your acute treatment strategy. 1, 2