Specific prescribing question

QuestionsCategory: QuestionsSpecific prescribing question
Patricia D'Encarncao Blose MD asked 2 years ago

My daughter, Therese D’Encarncao, has been treated for traumatic brain injury due to a gunshot wound. Her initial doctor was a neurologist and pain specialist and after much work up and trials found that Fiorinal worked well for her along with gabapentin and a number of other interventions. She has been tried on many different kinds of Therapies. She has moved out of state and then had to move again because of her husband’s job. It appears she may have to move again. Every time she moves and find a new doctor they want to do the whole work-up over again and everybody wants to get her off of fiorinal. Do you prescribe fiorinal?

Patricia D’Encarnacao Blose MD,
Board certified psychiatrist 1979
With added qualifications in Addiction Psychiatry (1993 – 2003)

1 Answers
PainDr Staff answered 2 years ago

Dr. DB; Fiorinal (and Fioricet) have fallen out of favor due to their risk of causing rebound headaches and other toxicities. Many years ago I had a patient who seemed only to respond to Fioricet after multiple attempts to replace it. These were the days before we had other options like multiple tryptans, CGRP inhibitors, g-pants, etc.  Finally, we tried a combination off-label but that possibly could offer similar pharmacology without the peaks and troughs seen with Fioricet (butalbital plus acetaminophen and caffeine). With careful serum drug level monitoring, we replaced the Fioricet with low dose phenobarbital, acetaminophen, and theophylline. The latter has similar properties to caffeine. It worked well, but there is no literature to support this combination to replace Fioricet, and it would most probably be difficult to find a neurologist to try this, nor am I suggesting it would be an option today. With all the new migraine medicines, since the patient I described, such as tryptans, CGRP inhibitors, g-pants, etc., assuming that the headache type being treated is a migraine, it makes sense that a neurologist would want to try conventional therapies with proven efficacy.  Fiorinal is a pretty sloppy drug with a poor track record long term.