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Fiorinal is a combination analgesic medication consisting of acetylsalicylic acid, the barbiturate butalbital and caffeine. Some formulations also contain the opioid codeine. It is used to treat tension headaches and migraines. The mechanism of action is not well understood. Since butalbital is habit-forming, using fiorinal daily can lead to dependency. Fiorinal #3 contains: 30 mg codeine, 50 mg butalbital, 40 mg caffeine, and 325 mg aspirin. Used for severe dental pain (1-2 cap q4h prn).

Other brand names include Fiormor®, Fiortal®, Fortabs®, and Laniroif®.

Folic acid
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A Comprehensive Medicine approach to migraines
From Townsend Letter for Doctors and Patients, 1/1/05 by Jacob Teitelbaum

For this pain issue, I have excerpted part of the section on the treatment of migraines from my new book Pain Free 1-2-3!-A Proven Program to Get You Pain Free (the book and info on our Hawaii February 4-6, 2005 pain management conference are available at The book teaches a Comprehensive Medicine approach to overall pain management for both prescribing and non-prescribing practitioners.



These headaches can be very severe and often leave people crippled for days. They may afflict as many as 28 million Americans. Migraines are often preceded by an "aura," which may consist of visual disturbances such as flashing lights. The headaches are often associated with nausea, sweats, dizziness, and slurred speech. Light and sound sensitivity can also be severe.

There is still marked debate over the cause of migraines. For decades, researchers thought that these occurred because of excessive contraction and expansion of the blood vessels in the brain. Others thought that this blood vessel problem occurred because of inadequate serotonin, the neurotransmitter that controls sleep and mood, which also plays a role in how blood vessels expand. Low serotonin also amplifies pain by increasing the pain neurotransmitter called substance P. Muscle spasm and nutritional imbalances and deficiencies can also contribute to migraines, as can food sensitivities. Most likely, it is a common endpoint for many different underlying problems.

Effective migraine treatment is important. Not only are migraines horribly painful, but they are expensive as well. The average amount of work missed by those with migraines is 19.6 days a year, costing employers $3000 per year per employee. It is also under-treated, with 31% of migraine patients never having sought treatment. (6)

What Medications Can I Take to Get Rid of an Acute Migraine Headache?

In the US, medications in the Imitrex[R] family still remain the first choice. This new family of medications, called triptans, has increased our ability to dramatically treat migraine headaches effectively. Imitrex comes in 25,50, and 100 mg tablets, and up to 100 mg may be taken at a time. If pain persists at 2 hours, another dose of up to 100 mg can be taken. In addition, it is also available by nasal spray, using a dose of up to 20 mg initially, followed by one more spray of up to 20 mg 2 hours later if needed. Another alternative is a 6 mg subcutaneous injection, which can also be repeated 1 hour later if needed. It is reasonable to try these different forms to see what works best for your migraines. You may also want to try a newer cousin called Amerge[R]. Use 2.5 mg initially. This dose may be repeated 4 hours later if needed. Your physician may also use other related medications such as Zomig[R], Axert[R], or Relpax[R].

Imitrex has been found to be effective in eliminating an acute migraine attack in 34 to 70% of patients within 2 hours. Unfortunately, at least 30 to 40% of patients remained unsuccessfully treated. (7) Axert[R] (almotriptan 6.5 to 12.5 mg, which can be repeated in 2 hours) is similar in effectiveness to Imitrex but less expensive ($10.50 vs. $16.50).

Other treatments may be effective for acute migraine when Imitrex is not. Aspirin family medications do not work well in migraines because the absorption of aspirin is delayed during the migraine attack. To combat this problem, medications that enhance absorption can be added to the aspirin and/or it can be given by suppository. For example, a combination of indomethacin (a "super-aspirin"), prochlorperazine (for nausea and to enhance absorption), and caffeine in suppository form were compared with Sumatriptan[R] rectal suppositories for acute migraines. Forty-nine percent of patients were pain free at 2 hours on the first treatment as compared to 34% with the Sumatriptan. (8) Another study using a similar approach had the same result. Aspirin (lysine acetyl salicylates 1620 mg -- equivalent to 900 mg of aspirin) was combined with Metoclopramide[R], 10 mg. The latter medication returns the absorption of aspirin to normal during migraine attacks and also combats nausea and vomiting. In the two placebo-controlled studies, this combination was more effective than 100 mg of Imitrex by mouth and was better tolerated. (9-11) These combinations can be made by compounding pharmacists. It is quite likely that regular aspirin, especially if chewed, would be as effective as the form used in the study. Metoclopramide is readily available.

Other medications can also be helpful for acute migraines. Many patients get relief with Midrin[R], which is a mix of three medications. Take 2 capsules immediately followed by 1 capsule every hour until the headache is relieved (to a maximum of 5 capsules within a 12 hour period). It can also be helpful for tension headaches in a dose of 2 capsules 4 times a day, as needed. Many patients find this to be quite helpful and it is not addictive. Fiorinal[R] can also be effective but is addictive, and I prefer not to use this medication.

A fascinating study can guide you as to when to use Imitrex family medications vs. when to go with other therapies. At last year's American Academy of Neurology meeting, Dr. Burstein of Harvard Medical School noted that 75% of migraine patients get painful sensitivity to normal touch (e.g. from eyeglasses) around their eyes. This pain is created in a different part of the brain than the throbbing pain that gets worse with movement or coughing. The study found that if you use Imitrex before you get the tenderness/pain around the eyes, it will knock out the migraine 93% of the time. If the pain/tenderness around the eyes had already set in, Imitrex only eliminated the migraine 13% of the time (although it still helped the throbbing). In other words, if you are one of the lucky ones who does not get pain around the eyes, the Imitrex can knock out your migraine at any time. If you are one of those who get pain/tenderness around the eyes, it is a race against the clock to take the Imitrex before that pain starts. This means, take the Imitrex early in the attack (within the first 5 to 20 minutes) before the skin hypersensitivity gets established. For example, use it at the earliest warning signs like painful scalp or discomfort from wearing your glasses, shaving or wearing earrings. If the pain has already fully set in before you take the Imitrex, consider using one of the other acute treatments we've discussed. (12)

Because of the nausea and light/sound sensitivity, anti-nausea medications can also be helpful. Phenergan[R] or Compazine[R] suppositories are two such medications.

What Natural Remedies Can I Use to Knock Out an Acute Migraine?

Two natural treatments can knock out an acute migraine. The first, which you can take at home on your own, is butterbur. This herb can both prevent and eliminate migraines. Take 50 mg 3 times a day for 1 month and then 50 mg twice a day to prevent migraines. You can take 100 mg every 3 hours to eliminate an acute migraine. Use only high quality brands (e.g.-Integrative Therapeutics). Many others that were tested had impurities and did not contain the amount of butterbur the label claimed (i.e. they don't work).

In a hospital emergency room or a doctor's office, intravenous magnesium can effectively eliminate an acute migraine. In one study of 30 patients with moderate or severe migraine attacks, half received 1 g of magnesium sulfate IV over 15 minutes and the other half placebo. Those in the placebo group who were not better by a half-hour were then treated with the magnesium. Immediately after treatment, at 30 minutes, and at 2 hours, 86% in the magnesium group were pain-free with the other 14% showing a reduction in pain. Associated symptoms such as nausea, light sensitivity, and irritability also resolved, and none of the patients in the magnesium group had a recurrence of pain within 24 hours. In the placebo group, no patient became pain free, and only one had a reduction in pain. When patients in the placebo group were later given the magnesium, responses were similar to subjects in the other magnesium treated group. Mild side effects, which are a normal effect of magnesium working to open blood vessels, such as a burning sensation in the face and neck, flushing, and a drop in blood pressure of 5 to 10 mm systolic occurred in 86% of the patients. None of these side effects was serious, and no patient had to discontinue the treatment. (13) These results were similar to those in previous reports. (14,15)

I'm Happy I can Eliminate an Acute Migraine Headache, but How Can I Prevent Them?

In addition to being able to treat acute migraines more effectively, many medications can prevent them. Together, these medications reduce the number of headache days per month by an average of 50%. (17) These medications include beta-blockers (Inderal[R]), calcium channel blockers, Neurontin[R], Depakote[R], Topamax[R], Elavil[R], and Doxepin[R]. Although Inderal XL can be helpful, it may aggravate fatigue, asthma, or depression. Another medication that can be helpful is Zonegran 100 mg. This is an anti-seizure medication. Begin with 100 mg a day for 2 weeks and then increase to 2 tablets a day. The maximum dose is 400 mg daily, although most of the benefit occurs at the first 200 mg. Because there have been rare occurrences of a life-threatening rash (most rashes caused by the medication are not, however), stop the medication immediately if you get a rash. Do not use this medication if you are allergic to sulfa drugs.

Fortunately, natural remedies are even more effective in preventing migraines. They may take up to 3 months to start working, however, so the above medications can be used while you're waiting for the natural preventives to take effect. Magnesium by mouth has been found to be effective for migraine prevention and is as effective as Elavil[R]. (18) Magnesium serves in an enormous number of functions in the body, including the relaxation of muscles and arteries. Most Americans get nowhere near the optimum amount of magnesium in their diet, getting less than 250 mg a day as opposed to the 650 mg that the average Chinese diet supplies. Blood testing to check magnesium levels are horribly unreliable and may not detect magnesium deficiency until it is severe.

A leading authority on natural prevention of migraine headaches is Dr. Alexander Mauskop, author of What Your Doctor May Not Tell You about Migraines. As discussed above, in 1995 Dr. Mauskop published a study showing that intravenous magnesium could abort a migraine headache. (19) He also found that intravenous magnesium could knock out other types of headaches as well. (20) This powerful data spurred researchers to see whether magnesium could also prevent migraines. As noted above, the answer was yes. In one German placebo-controlled study patients were given 600 mg of magnesium daily for 12 weeks or a placebo; there was a significant drop in migraine frequency in the magnesium group. (21) Another study shows similar effects in women with menstrual migraine (see below). (22) It is a good idea for most migraine patients to take 150 to 200 mg of magnesium in the morning (present in the vitamin powder) and again with dinner or at bedtime (less if diarrhea is a problem).

Riboflavin (vitamin B2) assists in the production of energy. In one study, migraine patients were given riboflavin 400 mg with breakfast every day for at least 3 months. By the end of the study they had a 67% decrease in migraine attacks as well as a decrease in attack severity. This was later repeated in a placebo-controlled study. (23) Note that it can take 3 months for the riboflavin to start working.

Vitamin B12 can also decrease migraine frequency. In one study in which patients received 1000 micrograms a day as a nasal spray, migraine frequencies decreased by an average of 43% after 3 months (the vitamin powder/B-complex contains 500 micrograms a day). (24)

Feverfew is another helpful herb for migraine prevention. (25) Using feverfew has resulted in a significant reduction in migraines in one-third of patients. It was also found to be very safe. (26)

Butterbur is a shrub that grows in Europe, Asia, and Africa. A standardized extract called Petadolex[R] was used in two double-blind studies. By the third month, those receiving active treatment with 100 mg a day had 60% fewer migraine attacks than the control group. Although 100 mg a day is effective, 75 mg twice a day with food may be the optimal dose. (27)

Fish oil has also been found to decrease the frequency of migraines. In two placebo-controlled studies of patients with frequent severe migraines that did not respond to medication, fish oil was found to be effective. Use 1 to 2 tbs a day and give the treatment 6 weeks to see the effect. Then you can decrease it to the lowest dose that maintains benefit. (28,29)

Other natural compounds that may be helpful include glucosamine 1500 to 2000 mg a day (this compound was found to be helpful in a small study of 10 patients over 4 to 6 weeks). Coenzyme Q10, 150-200 mg daily, decreased the average number of migraine attacks per month from 4.8 to 2.8 in an open study. (30)

All this suggests that many, if not most, migraines can be prevented naturally. I would begin by taking the vitamin powder plus 300 mg of Vitamin B 2 in the morning, plus 200 mg of magnesium at night. If the cost is not prohibitive, I would add butterbur as well. Also check for food allergies, as noted below, and follow the advice for hormones if the migraines are predominately around your periods or associated with taking estrogen. I have seen this approach commonly eliminate frequent and severe migraine problems, but remember that it may take 3 months to see the effect.

What Else Can I Do to Eliminate the Underlying Cause of the Migraines?

Acupuncture is another option to consider for chronic migraine and tension headaches. It results in reduced pain, reduced frequency of headaches, and improved function, energy, and health. In two studies conducted in New York City and London, acupuncture was found to be cost-effective. In a randomized controlled study of 401 patients with chronic headaches (the majority having migraines), patients received up to 12 acupuncture treatments over a 3-month period vs. a control group that received standard care. The acupuncture patients had 22 fewer headache days per year, 15% fewer sick days, and 25% fewer visits to the doctor. (31)

Food allergies are also very important to consider. Approximately 30 to 50% of migraine patients get marked improvement by avoiding certain foods, and most people with migraines are not aware of what foods are triggering their headaches. This has now been demonstrated in at least four placebo-controlled studies. Food sensitivities are an even bigger problem in children with migraines. (32-35) To determine if foods are playing a role in causing your headache, it is helpful to do an elimination diet. This requires eating a very limited diet for five days. Eat only pears and lamb, and drink only bottled spring or distilled water. This kind of strict elimination diet will make it easier to tell if food allergies/sensitivities are present and triggering your migraines when you reintroduce foods into your diet. In one study, by avoiding the ten most common food triggers, subjects exhibited a dramatic reduction in the number of headaches per month, with 85% becoming headache free. Twenty-five percent of the patients with high blood pressure also had their blood pressure reduce to normal. The most common reactive foods were wheat in 78% of patients, oranges in 65%, eggs in 45%, tea and coffee in 40% each, chocolate and milk in 37% each, beef in 35%, and corn, cane sugar, and yeast in 33% each. Some studies also suggest that the artificial sweetener aspartame (NutraSweet[R]) can trigger migraines and other headaches, although this is controversial. (36,37) If you have severe and frequent migraines, it is definitely worth exploring food sensitivities. (38) You may find that instead of avoiding foods that trigger your migraines for the rest of your life, you can eliminate the sensitivities/allergies using a powerfully effective acupressure technique called NAET (see

Jacob Teitelbaum MD is director of the Annapolis Research Center for Effective CFS/Fibromyalgia Therapies, which sees patients with CFS/FMS from all over the world (410-573-5389; and author of the best selling book From Fatigued to Fantastic! and Three Steps To Happiness! Healing Through Joy. His newest book, Pain Free 1-2-3!, has just been released. He gives workshops on effective CFS/Fibromyalgia therapies and pain management for both prescribing and nonprescribing practitioners (see He accepts no money from any company whose products he recommends and 100% of his royalty for products he makes is donated to charity.


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2. Oliver RL. Choosing the right triptan. Practical Pain Management. January/February 2003; Page 15-18.

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4. Lancet 1995; 346:923-926.

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6. Marcus, D.A. Headache and Pain, Nov 2003.p 180-185.

7. Oliver, R.L. "Choosing the right triptan." Practical Pain Management, January/February 2003; pp 15-18.

8. Headache, 2003 Sep; 43(8):835-844.

9. Lancet, 1995; 346:923-926

10. Functional Neurology, 2000; 15 supplement 3: 196-201.

11. Wilner AN. Pain Medicine News. Vol 1 #4 p1 & 5, 2003.

12. Wilner AN. Pain Medicine News. Vol 1 #4 p1 & 5, 2003.

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22. Facchinetti F, et al. magnesium prophylaxis of mention migraine: effects on intracellular magnesium. Headache 1991 May; 31 (5): 298-301

23. Schoenen J, et al. High-dose riboflavin as a prophylactic treatment of migraine: results of an open pilot study. Cephalgia 1994 October; 14 (5): 328-9. & Schoenen J, et al. Effectiveness of high-dose riboflavin in migraine prophylaxis. A randomized controlled trial. Neurology 1998 February; 50 (2): 466-70.

24. Van Der Kuy PHM, et al. Hydroxycobalamin, a nitric oxide scavenger, in the prophylaxis of migraine: an open, pilot study. Cephalgia 2002; 22:513-519.

25. Murphy JJ, et al. Randomized double-blind placebo-controlled trial of feverfew in migraine prevention. Lancet 1988 July 23; 2May (8604); 189-92.

26. Prusinski A, et al. Feverfew as prophylactic treatment of migraine. Neurol Neurochir Pol 1999;33 supplement 5:89-95.

27. Brown DJ. Standardized butterbur extract Petadolex--herbal approach to migraine prophylaxis. Townsend Letter for Doctors and Patients, October 2002

28. Glueck CJ et al. Amelioration of severe migraine with omega-3 fatty acids: a doubleblind placebo-controlled clinical trial. Abstract. American Journal of Clinical Nutrition 43:710, 1986.

29. McCarren T. et al. Amelioration of severe migraine by fish oils. Abstract. American Journal of Clinical Nutrition 41:874 a, 1985.

30. Rozen TD, et al. Open label trial of coenzyme Q10 as a migraine preventive. Cephalgia 2002 March; 22 (2): 137-41.

31. British Medical Journal Online 2004: 10. 1136/bmj.38029.421863.EB

32. Mansfield L. E., Food allergy and migraine. Postgraduate Medicine 83 (7): 46-55, 1988

33. Mansfield L. E. et al. Food allergy and adult migraine. Annals of Allergy 55:126, 1985

34. Monroe J, et al. Migraine is a food allergic disease. Lancet 2: 719-21, 1984

35. Egger J et al. Is migraine food allergy? Lancet 2: 865-9, 1983

36. Lipton R et al. Aspartame as a dietary trigger of headache. Headache 29:90-92, 1989.

37. Koehler SM, et al. The effect of aspartame on migraine headaches. Headache 28 (1): 10-14, 1988

38. Grant ECG. Food Allergies and Migraines, Lancet, May 5, 1979; 966-969

by Jacob Teitelbaum, MD

COPYRIGHT 2005 The Townsend Letter Group
COPYRIGHT 2005 Gale Group

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