Should butalbital-containing analgesics be banned? Yes.

Young WB, Siow HC.

Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, 111 South 11th Street, Philadelphia, PA 19107, USA. William.B.Young mail.tju.edu

In the United States analgesic-overuse headache is often caused by butalbital-containing analgesics. These agents can cause physical and psychological dependency, and dangerous withdrawal syndromes. Butalbital-containing analgesics have already been banned in several European countries. They are proven effective in tension-type headache, but not in migraine; there are many alternative treatments for migraine and tension-type headache. In the 20 years since analgesic overuse headache was widely recognized, butalbital overuse has remained distressingly common. It is time to ban these agents.

Publication Types:

• Review





Butalbital in the treatment of headache: history, pharmacology, and efficacy.

Silberstein SD, McCrory DC.

Jefferson Headache Center, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA.

Analgesics containing butalbital compounded with aspirin, acetaminophen, and/or caffeine are widely used for the treatment of migraine and tension-type headache. The butalbital-containing compounds are efficacious in placebo-controlled trials among patients with episodic tension-type headaches. Despite their frequent clinical use for migraine, they have not been studied in placebo-controlled trials among patients with migraine. Barbiturates can produce intoxication, hangover, tolerance, dependence, and toxicity. Butalbital can result in intoxication that is clinically indistinguishable from that produced by alcohol. Butalbital-containing analgesics can produce drug-induced headache in addition to tolerance and dependence. Higher doses can produce withdrawal syndromes after discontinuation. Butalbital-containing analgesics may be effective as backup medications or when other medications are ineffective or cannot be used. Because of concerns about overuse, medication-overuse headache, and withdrawal, their use should be limited and carefully monitored.

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Isotopic analogs as internal standards for quantitative GC/MS analysis--molecular abundance and retention time difference as interference factors.

Chang WT, Smith J, Liu RH.

Department of Forensic Science, Central Police University, Taoyuan, Taiwan.

The following analyte/isotope-labeled internal standard (IS) systems are adapted to further study the interference phenomenon previously reported from our laboratory--the intensity ratio of the ion-pair designated for a specific analyte/2H-analog system increases as the solvent used to reconstitute the extraction/derivatization residue is increased: (a) Three analyte/2H-analog pairs with 2H-atoms positioned at allylic sites (butalbital, secobarbital, methohexital); (b) Two analyte/2H-analog pairs without these structural features (pentobarbital, phenobarbital); and (c) Two analyte/13C-analog pairs (butalbital, secobarbital). Major experimental parameters adapted in this study include: (a) Varying reconstitution solvent volume while keeping a constant analyte/IS concentration ratio; (b) Varying analyte/IS concentration ratio; (c) Varying gas chromatograph (GC) injection port temperature; and (d) Varying GC column temperature programming conditions, rendering difference in the degree of overlap of the peaks derived from the analyte and the 2H-analog. This study results in the following observations: (a) Changes in the intensity ratio of the ion-pair designated for a specific analyte/2H-analog system depend on molecular abundance, regardless of whether the 2H-atoms are positioned at active allylic positions or not--thus, ruling out hydrogen/deuterium exchange as the cause of the observed interference phenomenon; (b) Variations in GC injection port temperature do not alter the observed interference phenomenon-thus, ruling out chemical reactions at the injection port as the underlying cause; (c) Variations in peak-overlapping between the analyte and the 2H-analog, facilitated by changing GC column programming conditions, alter the observed interference phenomenon. Abundance of the analyte and the 2H-analog and their overlapping characteristic in the mass spectrometer ion source are believed to be the underlying cause of the observed interference phenomenon. The interference phenomenon observed for a specific analyte/2H-analog system has significant consequences on the linearity of the thereby generated calibration curves. Nonlinear approaches can better describe the calibration data and are needed more in comparison to systems in which 13C-analogs are used as the ISs.

Source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=&dopt=Abstract butalbital fioricet barbiturate




Do butalbital-containing products have a role in the management of migraine?

Wenzel RG, Sarvis CA.

Diamond Headache Clinic Inpatient Unit, St. Joseph Hospital, Resurrection Health Care, Chicago, IL 60657, USA. rwenz hotmail.com

STUDY OBJECTIVE: To evaluate the role of butalbital-containing products in the management of migraine. METHODS: Qualitative systematic search using MEDLINE (January 1966-November 2001), review of the United States Headache Consortium's evidence-based guidelines for migraine treatment, and review of other pertinent literature. RESULTS: Over 28 million people suffer with migraine, yet this illness is less than optimally diagnosed and managed. Between 14% and 36% of diagnosed migraineurs are prescribed butalbital-containing products, often as initial therapy. However, the only identified controlled trial of these drugs for migraine treatment showed that butalbital-containing products were inferior to butorphanol. The consortium's guidelines specifically discourage administration of butalbital-containing products for migraine. In addition, other published literature highlights the frequent adverse consequences of butalbital-containing products for migraineurs, such as poor migraine control, disability, drug-induced headaches, and withdrawal symptoms. CONCLUSION: Although butalbital-containing products commonly are prescribed for migraine, no evidence in the literature demonstrates their benefit over other agents or placebo. Drugs with proven migraine efficacy, as listed in the consortium's evidence-based guidelines, should be prescribed instead.

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Tension-type headache.

Millea PJ, Brodie JJ.

Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee 53226-0509,USA. pmillea mail.mcw.edu

Tension-type headache typically causes pain that radiates in a band-like fashion bilaterally from the forehead to the occiput. Pain often radiates to the neck muscles and is described as tightness, pressure, or dull ache. Migraine-type features (unilateral, throbbing pain, nausea, photophobia) are not present All patients with frequent or severe headaches need careful evaluation to exclude any occult serious condition that may be causing the headache. Neuroimaging is not needed in patients who have no worrisome findings on examination. Treatment of tension-type headache typically involves the use of over-the-counter analgesics. Use of pain relievers more than twice weekly places patients at risk for progression to chronic daily headache. Sedating antihistamines or antiemetics can potentiate the pain-relieving effects of standard analgesics. Analgesics combined with butalbital or opiates are often useful for tension-type pain but have an increased risk of causing chronic daily headache. Amitriptyline is the most widely researched prophylactic agent for frequent headaches. No large trials with rigorous methodologies have been conducted for most non-medication therapies. Among the commonly employed modalities are biofeedback, relaxation training, self-hypnosis, and cognitive therapy.

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Butalbital Online References

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