Question 1: What does the medical literature say about headache treatment with butalbital-containing medications in children?

Anecdotally, butalbital-containing medications do not appear to be widely prescribed for children by emergency practitioners, although we do occasionally treat pediatric patients who have been prescribed these drugs for headaches. Butalbital comes in two predominant combinations and, like other barbiturates, has the potential for tolerance and dependence. Clinical studies have addressed butalbital-containing medications in the treatment of tension-type headaches, and it’s supported by level C evidence according to the American Headache Society for migraine treatment.^1,2 Commonly referenced trade names include Fioricet (ie, butalbital-acetaminophen-caffeine) and Fiorinal (ie, butalbital-aspirin-caffeine).

We searched the literature but found no randomized controlled trials addressing headache treatment with butalbital-containing medications in children. Although not specific to children, these drugs also demonstrate teratogenic risks in periconceptional mothers, and this additional concern may translate to the adolescent female population.³

Summary

With no randomized studies in children, plus the potential tolerance and dependence risks, butalbital-containing medications probably shouldn’t be prescribed to children for headache.

Dr. Jones is assistant professor of pediatric emergency medicine at the University of Kentucky in Lexington.

Dr. Cantor is professor of emergency medicine and pediatrics, director of the pediatric emergency department, and medical director of the Central New York Regional Poison Control Center at Upstate Medical University in Syracuse, New York.

References

1. Silberstein SD, McCrory DC. Butalbital in the treatment of headache: history, pharmacotherapy, and efficacy. Headache. 2001; 41(10):953-967.
2. Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the American Headache Society evidence assessment of migraine pharmacotherapies. Headache. 2015;55(1):3-20.
3. Caruso A, Lazdowsky L, Rabner J, et al. Butalbital and pediatric headache: stay off the downward path. Headache. 2015;55(2):327-330.