Why Do Migraineurs Abuse Butalbital‐Containing Combination Analgesics?

Abstract

(Headache 2010;50:1194‐1197)

A Rational Approach to the Management of Chronic Migraine

“…Triptans on 10 or more days a month or simple analgesics or any combination of triptans and analgesic opioids on 15 or more days per month on a regular basis for more than 3 months without overuse of any single class alone may result in medication‐overuse headache (MOH) . Of course, in addition to causing medication overuse, chronic use of butalbital and opiates can lead to habituation and other side effects.…”

Daily Triptan Use for Intractable Migraine

“…By comparison, there are a number of serious safety concerns with daily or almost daily use of opioids, opioid combinations, 8 or butalbital combinations. 9 In addition, the combinations may contain acetaminophen, which is the leading cause of death from over-the-counter medications, and over a period of a decade resulted in 1567 deaths from liver failure due to accidental overdoses. 10 Indications for Daily for Near-Daily Triptan Use.-With regard to the indications for daily or neardaily triptan use, it is not an established treatment and, therefore, there are no specific indications.…”

“…By comparison, there are a number of serious safety concerns with daily or almost daily use of opioids, opioid combinations, or butalbital combinations . In addition, the combinations may contain acetaminophen, which is the leading cause of death from over‐the‐counter medications, and over a period of a decade resulted in 1567 deaths from liver failure due to accidental overdoses …”

Risk Stratification With Opioid Therapy

“…3 As prescriptions for chronic opioid therapy grew, issues of drug diversion and opioid misuse significantly increased. 6,7 This reluctance may have been fortuitous, as no senior headache researchers or academic headache organizations were named in the recent US Senate investigation targeting undue pharmaceutical industry influence on education and clinical practice. In response to the drug diversion concerns, the government funded several studies which revealed that 70% of diverted medications came from a friend/relative, 80% directly from the physician or related healthcare provider, and only a small amount from street drug dealers.…”

“…5 Several factors may have led to the reluctance to embrace chronic opioid therapy for headache management, including a lack of supportive outcomes, the introduction of the triptans as an alternative, and the not-too-distant history of butalbital misuse that headache clinicians recalled from the 1980s and 1990s. 6,7 This reluctance may have been fortuitous, as no senior headache researchers or academic headache organizations were named in the recent US Senate investigation targeting undue pharmaceutical industry influence on education and clinical practice. 8 Despite resistance from the headache field, anecdotal reports on the use of opioids with chronic headache continued to appear in the literature.…”