Butalbital (Fiorinal) has been around since the 1920's when someone put together
aspirin, caffeine, and a short acting sedative, butalbital. Butalbital
is related to the longer acting phenobarbital. These are reasonably
good for migraine and tension headache, but can cause rebound headaches (when
used daily) and they are habit forming. 10% of the world is at risk
for becoming addicted because in those 10% of people they find that these
meds relieve anxiety/depression, give them a 'high or euphoric' feeling for
several hours, or give them more energy. 90% of people feel either
tired or no beneficial psychic feelings, and only take these for the intended
These meds are relatively cheap and well tolerated. They are not as
effective for migraine as the newer triptans (Imitrex, Zomig) or Migranal
nasal spray. The generic of the butalbital meds notoriously does not
seem to work quite as well; we try and order the 'Creighton' generic,
as I believe it is manufactured by the same house as the regular fiorinal.
Butalbital meds should not, in general (although there are certainly exceptions)
be utilized for daily headaches; limits need to be place on them.
While they are technically sedatives they can also, in addition to sedation,
cause increased energy or even insomnia.
These meds come in a variety of forms, each designed for a different time
and purpose; if someone has very much stomach upset, we use the type
without aspirin.... for those with insomnia and a sensitivity to caffeine,
the ones without caffeine are best. Aspirin and caffeine enhance the
efficacy of these meds, but there is a place for the ones without these
ingredients. Many patients have several types of the butalbital meds
around, and utilize different ones in certain circumstances.
The following shows the differences in the makeup between similar variations
of this medication:
Fiorinal= aspirin + caffeine + butalbital
Fioricet & Esgic= acetaminophen + caffeine + butalbital
(Esgic Plus is the same, with a bit more acetaminophen)
Phrenilin= acetaminophen + butalbital (Phrenilin Forte just
adds a bit more acetaminophen)
While Fiorinal is more effective than the others, you can see that each has
a role to play. Unless overused, these are very useful meds, even in
younger people and, in tiny doses (1/2 tablet) in children over age 9 or
so; not as a first line choice in kids, but as a second line medication.
Fiorinal with codeine adds 30mg of codeine to Fiorinal; Fioricet with
codeine adds 30mg of codeine to the Fioricet. These not only add
effectiveness with the narcotic addition, but also all of the side effects
of codeine. These meds are, of course, more addicting because of the
codeine. Again, in judicious amounts they can be very beneficial.
And occasionally, as a last resort, we do tolerate these on a daily basis
if people are dependent, NOT addicted (see previous section in What's New,
October, on addiction vs. dependence). As I tell doctors all the time
in my lectures, if you give a patient 30 Fiorinal, and they call 3 days later
and say "those were great, doc, can I have some more", you have a problem!
HOWEVER, despite the misconceptions, the overwhelming majority of people
do NOT overuse these, or any, drugs.