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HeadWay, Issue #023 -- What does my pharmacist know?
June 21, 2005

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In this month's issue:

Butalbital combination drugs

But my pharmacist knows...

Say what?! Pseudotumor cerebri

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Butalbital combination drugs

Thanks to Maryann from the USA, who said she would like to see more drug profiles in HeadWay. So, today we're talking about a group of combination drugs containing butalbital. The drugs I'm talking about are the ones commonly used for migraine and tension type headache. You may be most familiar with Fioricet, Fiorinal, Seconal and Esgic. But there are many other brand names for these drugs, such as Mebaral, Femcet, Endolor, Tuinal, Repan and Lanorinal. They come in a variety of forms.

Butalbital is a barbiturate, a derivitive of barbituric acid. The first medicinal barbiturate was synthesized in 1903. Barbiturates are used as anticonvulsants and pain medications. American movie star Judy Garland is believed to have died of an accidental barbiturate overdose.

The common combinations are:
1. aspirin + butalbital + caffeine (Fiorinal, Butalbital Compound, Lanorinal)
2. acetaminophen + butalbital + caffeine (Fioricet, Esgic, Femcet, Repan)
3. aspirin + butalbital + caffeine + codeine (Fiorinal with Codeine)
There are also combinations that don't include caffeine.

These are considered some of the more "heavy-duty" migraine drugs. The main danger is that these drugs can be very habit forming. So much so, that some countries in Europe such as Germany have banned the use of analgesics with barbiturates. If they're being taken more than a handful of times a month, they can cause rebound headache - a condition where the taking of the drug can cause more headaches even worse than the original ones.

What does it do?

Pain killers such as aspirin or acetaminophen are combined commonly with caffeine to heighten the effect of the painkiller. The butalbital works directly on the central nervous system. It acts as a depressant on nerves and muscles, and so is effective as a muscle relaxant or tranquilizer. The exact way they act on the nervous system to relieve headache is not fully understood.

Common warnings

You should always see your doctor before taking a new drug.  This should not be the first headache drug you try, but something to fall back on after you've tried the many other available treatments.  Your doctor will help you avoid overuse, and make sure you're not dealing with breathing problems, kidney or liver problems, diabetes, severe heart disease, porohyria or hyperthyroidism.

The most common side effects for these drugs include dizziness, sleepiness, nausea, slight stimulation, and sweating.

In summary, these are medications for those who have very difficult headache and migraine conditions that do not respond to other drug and non-drug therapies.  They should be taken with caution, and not on a regular basis.  If you're already taking them too often, see your doctor and read this article on rebound headache.

For more on headache and migraine abortives, read this summary.  Some butalbital combination drugs are available at, which is offering free shipping on your next $25+ non-prescription order (Ends 30 Jun 05).

But my pharmacist knows...

Pharmacists usually offer excellent, accurate and helpful advice when it comes to medications.  But a study from the Diamond Headache Clinic Inpatient Unit this past January does demonstrate reasons for caution.

200 surveys were sent out to pharmacists asking questions about their interaction with headache sufferers.  171 surveys were returned.  85% of the community pharmacists make 1-5 suggestions to headache sufferers every single day.

Over half of those surveyed felt that patients should try over the counter (OTC) drugs before prescription medications.  A third felt that migraineurs should try general headache painkillers before migraine-specific drugs.

Their answers showed that many were not aware of the latest guidelines for migraine treatment.  It may be that many were not aware of the benefits of migraine-targeted drugs.  About 2/3 did not feel that migraine was a neurological illness.

The researchers felt that many pharmacists were not aware of the latest migraine research and guidlines, and that they needed further training.  Be sure to stay informed yourself on the latest (wait - you're subscribed to HeadWay!  Good job!).  Your pharmacist is probably very knowledgeable, but you should still make sure you understand the basics and see your doctor for any new headache symptoms.

Say what?! Pseudotumor cerebri

Pseudotumor cerebri is a condition in which there's an increase in the pressure of fluid surrounding the brain and spinal cord, but no detectable problem in the CSF (pressure aside) or in the brain and spinal cord.  It's called "pseudo" because it mimics a brain tumour.  It commonly occurs in patients who are young, female and obese, and it's most common symptom is headache.  Certain medications, estrogen treatment, and vitamin A can bring on the condition, though its actual cause is unknown.
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