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Reader’s Mail: Side Effects for Cutting Back on Fioricet?

Q. I have been on Fioricet for 2 years. I had been taking 6 tablets a day. My physician recommended that I cut back, due to rebound headache, every 4 days. I have now cut back to 3 tablets, and I’m experiencing extreme drowsiness and agitation.  I was told it’s not a side effect. Do you have any recommendations for alternative medication(s) that I can try? Also, I would like to know if you’ve ever heard of anyone else experiencing these types of side effects.

A. Butalbital-containing medications such as Fioricet (butalbital/acetaminophen/caffeine) and Fiorinal (butalbital/aspirin/caffeine) have long been implicated in the development of rebound (medication overuse) headaches. One of the problems with Fioricet is that it has a long half-life of about 36 hours, which means that it takes 1.5 days for the body to eliminate half of the dose of the drug. It takes between 5 to 6 half-lives for the drug to reach a steady state, and you can still see traces of the drug in the blood and urine for more than 10 days after taking Fioricet or Fiorinal. There is an increased risk of tolerance and habituation to the drug when taking multiple doses daily. Weaning off the drug is usually done slowly since there is a risk of seizures and/or delirium. The severity of withdrawal symptoms is directly related to the amount of the medication taken and can include anxiety, weakness, nausea, vomiting, weight loss, involuntary muscle twitching, fatigue, decreased blood pressure, and dizziness. Withdrawal symptoms can be seen within 8 to 36 hours after the last dose is taken. A recent recommendation from the American Academy of Neurology has stated, “Don’t use opioid or butalbital treatment for migraine except as a last resort.” (Langer -Gould AM, Anderson WE, Armstrong MJ, et al. The American Academy of Neurology’s TOP Five Choosing Wisely recommendations. Neurology. 2013;81:1004-1011.)

Regarding alternatives in the treatment of migraine, the most important is the use of daily preventive medication(s) for long-term migraine control. This can include a single daily preventive medication or a combination of medications. Commonly prescribed daily preventive medications include beta blockers, antiepileptic medications, or tricyclic antidepressants. OnabotulinumtoxinA (Botox) is FDA-approved for the prevention of chronic migraine and can be an effective option in some patients. Last year, the FDA approved a device, Cefaly, which delivers microimpulses in order to stimulate nerve endings in the trigeminal nerve and may help to decrease migraine frequency. Treatment of migraine with acute medications such as triptans, ergotamine, or anti-inflammatory agents should be limited to no more than 2 to 3 days per week in order to prevent the development of rebound headache.

George R. Nissan, D.O.

Baylor Comprehensive Headache Center

Dallas, Texas

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