Butalbital, Aspirin, and Codeine

Painkiller butalbital, aspirin, and codeine is frequently used to treat tension headache and migraine, and is only available with a doctor’s prescription.

Overview

Butalbital, aspirin, and codeine combination medicines are painkillers most commonly used to treat tension headaches and migraine.

Butalbital is a barbiturate, and it works on the central nervous system (CNS) to relax the muscles. It is a sedative and therefore induces relaxation and sleepiness. Codeine also acts on the CNS, but it is a type of drug known as a narcotic analgesic, which means that it relieves pain. Both butalbital and codeine can become habit-forming drugs when consumed for long periods of time or in high doses. This means that people may experience physical and mental withdrawal symptoms when they stop taking the medicine.

Aspirin is a salicylate, which means that it works on reducing the number of substances in the body which cause pain, fever and inflammation. It is not a habit-forming drug, but it can cause harmful side effects when taken in high doses. Butalbital, aspirin, and codeine often include the ingredient caffeine which helps to increase the effects of aspirin and may also have mild pain-relieving properties. Caffeine can cause physical dependency when used for a very long time, and people may experience rebound headaches when they stop taking it if they have been taking butalbital, aspirin, and codeine or other medicines which contain caffeine for significant periods.

Since it contains narcotic drugs, butalbital, aspirin, and codeine is only available with a doctor’s prescription and cannot be purchased over the counter. It is administered orally in both capsule and tablet forms, and it is available under the following US brand names:

  • Ascomp with Codeine
  • Fiorinal with Codeine
  • Fiortal with Codeine

Condition(s) treated?

  • Tension headache
  • Migraine

Type of medicine?

  • Painkiller

Side Effects

Butalbital, aspirin, and codeine can cause unwanted side effects, some of which are minor, while others are serious and require medical care. Firstly, it’s important to familiarize yourself with signs of allergic reaction to the drug; if you notice any of these, seek emergency help immediately, particularly if more than one occurs at one time:

  • Coughing, wheezing, shortness of breath and tightness in chest
  • Difficulty swallowing
  • Severe dizziness or feeling faint
  • Skin rash or itching
  • Hive-like swellings on face, eyelids, lips or tongue
  • Flushing, redness or bluish discoloration of the skin (when it occurs with any other effects on the list)
  • Stuffy nose (when it occurs with any other effects on the list)

The following are potential side effects of butalbital, aspirin, and codeine; although they are rare, they’re very serious and require urgent medical attention:

  • Chest pain
  • Unexplained sore throat
  • Fever (either with or without chills)
  • Painful or swollen glands
  • Bleeding, crusting lip sores
  • Painful white spots, ulcers or sore in mouth
  • Red, thickened or scaly skin
  • Tender, burning or peeling skin
  • Pinpoint red spots on the skin
  • Abnormal bruising or bleeding
  • ack tarry or bloody stools
  • Blood urine
  • Confusion
  • Depression
  • Unusual excitement
  • Uncontrolled muscle movement or trembling
  • Tiredness or weakness

The following side effects are reasonably common and minor, which means they don’t require urgent medical attention. Although they often go away quickly after starting butalbital, aspirin, and codeine for the first time, if they do persist you could refer them to your doctor. You may be able to adjust some lifestyle factors to minimize the side effects. In other instances, you may find you can put up with them in exchange for the pain-relieving benefits of the drug.

  • Mild dizziness, drowsiness, and lightheadedness
  • Bloating and excess gas
  • Heartburn or indigestion
  • Nausea, stomach pain or vomiting

Note that if vomiting lasts for more than a couple days, you should report it to your doctor. Prolonged vomiting could lead to dehydration and other complications. If you experience stomach pain or vomiting with any symptoms of overdose, seek urgent medical care.

This list of side effects may not be exhaustive; if you notice any other unwanted effects when taking butalbital, aspirin, and codeine, consult your doctor or report them to the FDA.

Signs of overdose

When butalbital, aspirin, and codeine is taken in large doses, it poses a risk of overdose which can lead to respiratory depression and other complications. An overdose of this drug can be deadly. Symptoms of overdose include:

  • Seizures (convulsions)
  • Severe weakness
  • Slow or troubled breathing
  • Confusion
  • Severe nervousness
  • Severe excitement
  • Severe restlessness
  • Ringing or buzzing in ears
  • Hearing loss
  • Severe dizziness
  • Severe drowsiness

The same symptoms will occur if alcohol is consumed at the same time as butalbital, aspirin, and codeine.

Dosage

Recommended dosage

The recommended, average dose of butalbital, aspirin, and codeine for adults is usually one or two capsules or tablets taken as needed. Each dose should be spaced at least 4 hours apart, and no more than six capsules or tablets should be taken within one day. You should only take a dose when you notice a headache start, and shouldn’t try to take the drugs to prevent headaches unless you’re experiencing warning symptoms of headache and feel confident that pain is about to strike.

Dosages of butalbital, aspirin, and codeine will vary from patient to patient depending on a range of factors, such as the severity of their symptoms, their age and weight, what other medicines they are currently taking and other health conditions they suffer from. Always follow your doctor’s directions rather than the recommended or average doses mentioned here.

In children, the dose of butalbital, aspirin, and codeine must be determined by a doctor. Children may be particularly sensitive to this drug compared to adults, and should, therefore, be assessed on a case-by-case basis when prescribed it.

How to take butalbital, aspirin, and codeine

This drug offers the most relief for headaches when consumed as soon as the headache begins. If you tend to get warning signs of headache before the pain fully starts, it is possible to take the medicine as soon as you feel sure that a headache is coming. Not only will this reduce the severity of the headache but in some cases, it may stop the headache from occurring at all.

Lying down in a dark, quiet room can help to relieve headaches, so it recommended that you do this as soon as you have taken butalbital, aspirin, and codeine if possible. The tablets or capsules should be taken with either 8 ounces of water or food to reduce stomach irritation.

Butalbital, aspirin, and codeine is designed to relieve headaches as they occur and should be taken only when a headache strikes. They do not prevent headaches when taken regularly. If the headaches you suffer from are very persistent, your doctor may prescribe headache-preventing medicines. These should be taken on a regular basis as directed by your doctor, and pain-relieving medicines like butalbital, aspirin, and codeine should be taken in addition as needed. It can take several weeks for headache-preventing medicines to work, but once they get to work on the body you may be able to take pain-relieving medications less frequently.

Missed doses

Since butalbital, aspirin, and codeine should only be taken as needed, it isn’t a problem if you miss a dose. Just ensure that you are not taking doses more frequently than every two hours.

Interactions

It’s vital that your doctor knows about all medicines you are currently taking, including those which are prescribed and those bought over the counter. Certain medications can interact with butalbital, aspirin, and codeine and cause complications or increase the risk of dangerous side effects.

The following medicines are should not be taken at the same time as butalbital, aspirin, and codeine, and if you are currently taking them your doctor may consider an alternative painkilling treatment or they may change some of the other medicines you take:

  • Defibrotide (Defitelio)
  • Dichlorphenamide (Daranide, Keveyis)
  • Influenza Virus Vaccine, Live (FluMist)
  • Ketorolac (Sprix)
  • Naltrexone (ReVia)

There are many other medicines which also interact with butalbital, aspirin, and codeine but doctors may choose to prescribe them concurrently if the benefits of all drugs involved far outweigh the increased risk of complications and side effects. Dosing and other administration instructions may be adjusted to minimize the risk of side effects. Your doctor should know about all the medicines you are currently taking, but particularly:

  • Antibiotics and antifungal medicines
  • HIV or AIDS medicines
  • Seizure medicines
  • Heart and blood pressure medicines
  • Opioid pain medicines
  • Prescription cough medicines
  • Sleeping pills
  • Muscle relaxers
  • Sedatives
  • Tranquilizers
  • Antipsychotic medications
  • Drugs which affect serotonin levels, such as:
  • Antidepressants
  • Parkinson’s disease medicines
  • Migraine headache medicines
  • Anti-nausea medicines

Anti-clotting medicines such as:

  • Lopidogrel
  • Rivaroxaban
  • Warfarin
  • Coumadin

NSAIDs such as:

  • Diclofenac
  • Ibuprofen
  • Ketorolac
  • Naproxen

Medical interactions

Your doctor should know about your full medical history, because butalbital, aspirin, and codeine may interact with certain medical problems and either make them worse, increase the risk of side effects or cause other complications.

For people with a history of alcohol abuse, drug abuse or drug dependency, the chance of developing a dependency on butalbital and/or codeine is increased.

People with the following medical conditions are at an increased risk of serious side effects:

  • Brain disease
  • Head injury
  • Hyperactivity in children
  • Asthma (particularly if occurring with nasal polyps or allergies)
  • Emphysemia
  • Chronic lung disease
  • Colitis
  • Convulsions or seizures
  • Liver disease
  • Kidney disease
  • Gallbladder disease
  • Gallstone
  • Enlarged prostate
  • Urination problems

Butalbital is known to make the following medical conditions worse:

  • Depression
  • Diabetes mellitus
  • Porphyria
  • Overactive thyroid

Aspirin is known to worsen gout and can reduce the effectiveness of gout medicines. It can also worsen stomach ulcers, particularly in those with a history of bleeding. In individuals with vitamin K deficiency, hemophilia and other bleeding problems, aspirin increases the risk of serious bleeding.

Finally, butalbital, aspirin, and codeine is not suitable for those with severe heart disease, because the caffeine it contains can worsen the condition.

Warnings

Risk of dependency

Both butalbital and codeine are habit-forming drugs when consumed for long periods of time. The risk of dependency is managed by prescribing butalbital, aspirin, and codeine only for the very shortest periods of time necessary and at the lowest doses needed to reduce pain. Do not continue taking the medicine for longer than directed, and never take a higher dosage than prescribed.

If you take other similar pain-relieving medicines for frequent headaches, including those purchased over the counter, you may be at an increased risk of physical dependency. Be sure to let your doctor know about any other pain-relieving drugs you take regularly so that they can advise you on how to reduce the risk of dependency.

If butalbital, aspirin, and codeine suddenly stops working as successfully as it did when you first started taking it, consult your doctor. This is a sign that you could be developing a dependency on the medicine. Don’t take higher doses of the medicine to achieve the same level of pain relief. Instead, visit your doctor.

Similarly, if you find you’re having headaches more often than you did before you started taking it, you may be developing a dependency. You should take particular note if the headaches:

  • occur within less than 1 day of your last dose of the medicine
  • occur every day
  • continue for several days.

If you have been taking butalbital, aspirin, and codeine for a significant length of time and no longer need to take it, your doctor may choose to gradually reduce your dosage of the drug rather than have you stop taking it all of a sudden. Always follow the instructions given to you by your doctor when tapering off your dosage, as this will prevent physical withdrawal symptoms.

Patients with a history of narcotic abuse, misuse or addiction are also at an increased risk of dependency. Doctors may manage this risk by prescribing smaller quantities of the drug more frequently than normal. In the highest risk cases, the drug may not be prescribed at all and other pain-relief treatments might be tried first.

Risk of Reye’s syndrome in children with fever

Aspirin can cause a serious condition known as Reye’s syndrome when consumed by children with viral infections, such as the flu or chicken pox. Reye’s syndrome causes swelling in the liver and brain and can be life-threatening. If you think your child may have a viral infection or is showing signs of fever when they require a dose of butalbital, aspirin, and codeine, always consult your doctor first.

Even if a child doesn’t have a viral infection but does have a fever, or if they have lost lots of fluid due to severe sweating, vomiting or diarrhea, aspirin should be avoided as the child may become more sensitive to it. Always seek your doctor’s approval before giving them any medicine which contains aspirin, including butalbital, aspirin, and codeine, in these circumstances.

Other warnings for children

Butalbital tends to cause drowsiness since it is a CNS depressant. However, in some children, it can cause the opposite effect and make them very excited. If you find your child becomes unusually excited every time they take butalbital, aspirin, and codeine and it is having a detrimental impact on them, consult your doctor.

Warnings for elderly patients

Elderly patients tend to especially sensitive to butalbital, aspirin, and codeine. This is because their renal function tends to be decreased due to their age, which can cause the drugs to stay in the body for much longer, thus emphasizing their effects. This could increase the risk of side effects associated with drugs and, in the case of butalbital, it may lead to confusion, depression or unusual excitement.

Despite these increased risks, overall butalbital, aspirin, and codeine is safe for use in elderly patients. Doctors may require more careful monitoring of the patient or they may administer lower doses to reduce the risk of side effects.

Use during pregnancy and breastfeeding

Butalbital, aspirin, and codeine should not be consumed during the third trimester of pregnancy, and during the first two trimesters it should only be used if absolutely necessary. This is because aspirin, particularly during the third trimester, can increase the risk of premature closure of the fetal ductus arteriosus, which could lead to heart dysfunction in the fetus and other complications. It may also cause increased bleeding for the mother during labor.

Furthermore, since butalbital, aspirin, and codeine contain codeine, an opioid, prolonged use of the drug during pregnancy could lead to physical dependency in the baby when it is born. Physical dependency in newborns could cause life-threatening health complications. Ultimately, the drug should be used with great caution throughout the first and second trimesters, and not at all during the third trimester.

Butalbital, aspirin, and codeine is excreted in human breast milk, which means that it will be consumed by nursing infants when the mother is taking this drug. The amount of the drug secreted is usually very low, but the amount of codeine secreted can increase in women who are ultra-rapid metabolizers of morphine, which can cause the baby to develop dangerously high morphine levels. Due to the risk, breastfeeding is not recommended for women who are taking butalbital, aspirin, and codeine.

Consumption with alcohol and other CNS depressants

Both butalbital and codeine are CNS depressants and pose a risk of respiratory depression, in which breathing slows down. The risk of respiratory depression is heightened when the drugs are taken at the same time as other CNS depressants, which includes:

  • Antihistamines
  • Hay fever, allergy and cold medicines
  • Sedatives
  • Tranquilizers
  • Seizure medicines
  • Muscles relaxants
  • Anesthetics (including some dental anesthetics)

If you are already taking other CNS depressant for other health conditions, make sure your doctor knows about them when they prescribe butalbital, aspirin, and codeine. They may choose to adjust dosages of other medicines or give you new directions on when to take your various medicines.

Alcohol is also a CNS depressant and should be completely avoided when taking butalbital, aspirin, and codeine. Alcohol can also worsen headaches and migraines, and it can increase the risk of stomach problems associated with aspirin consumption, which are additional reasons to avoid it while taking this medicine.

Drowsiness and sleepiness

Since butalbital and codeine are CNS depressants, they can cause drowsiness, sleepiness and mild dizziness. These are relatively common and minor side effects, and don’t usually require medical attention. However, you should avoid driving or operating machinery while taking this medicine, unless you know how the drug affects you and feel that you can remain alert.

Dizziness, fainting, nausea and vomiting

Butalbital, aspirin, and codeine can cause dizziness, light-headedness and fainting, particularly when getting up quickly from sitting or lying positions. Bear this in mind when you first begin taking the drug and don’t yet know how it affects. You can avoid these effects by getting up slowly. Often, this side effect will dissipate once your body gets used to the drug.

Similarly, butalbital, aspirin, and codeine can cause nausea and vomiting, particularly when you first start taking the medicine. Lying down can help to reduce these effects. If vomiting continues after the first couple of doses, check with your doctor as it could be a sign of more serious side effects or complications.

Risks associated with excessive aspirin consumption

Aspirin is life-threatening if taken in high doses. It’s important that you avoid other medications that contain aspirin while taking butalbital, aspirin, and codeine to reduce the risk of overdose. Many over-the-counter painkillers, cold, flu and allergy medicines contain aspirin, so you should avoid taking these unless you have checked with your doctor whether it is safe to do so. Be sure to read the ingredients of these medicines carefully before using them, and remember that aspirin is often listed as ASA. If you’re in doubt about whether a product contains aspirin, check with your doctor or a pharmacist first.

Ultra-rapid metabolizers of codeine

When codeine is processed by the body it is turned into morphine. Some people are ultra-rapid metabolizers of codeine, which means that the drug is processed more quickly into morphine than is normal. This can result in excessive levels of morphine in the body, which can increase the risk of side effects. Individuals who have taken codeine in the past and discovered they were an ultra-rapid metabolizer of codeine may not be able to safely take it in the future, so make sure your doctor is aware of this.

Most people are unaware that they’re an ultra-rapid metabolizer of morphine until they experience negative side effects when they take the drug, such as:

  • Extreme sleeping
  • Extreme confusion
  • Very shallow breathing

If you notice any of these symptoms, seek medical care immediately.

Surgery warnings

It is vital that you let your healthcare provider know that you are taking butalbital, aspirin, and codeine before you undergo any type of surgery. The drug may cause serious side effects if it interacts with general or local anesthetics and other medicines used during surgery.

Be sure to check with your doctor or dentist whether it is safe to take butalbital, aspirin, and codeine in the days preceding planned surgery, as aspirin can cause bleeding problems. Generally, it is safer to stop taking butalbital, aspirin, and codeine 5 days before a surgery, unless your doctor advises you otherwise.

Potential interference with medical tests

Before you undergo any medical tests, be sure to let your healthcare provider know that you are taking butalbital, aspirin, and codeine. The caffeine in the drug can interfere with certain tests, such as those which use dipyridamole to demonstrate the rate of bloodflow to heart. Generally, caffeine should be avoided for 8 to 12 hours before tests of this nature, but always follow the advice of your healthcare provider.

Signs of aspirin breakdown

Aspirin gives a strong, vinegar-like odor when it is breaking down. Patients should not take butalbital, aspirin, and codeine if they notice this unpleasant aroma, as the medicine could be harmful. Instead, they should speak to their healthcare provider who will be able to provide replacement capsules or tablets. If you’re not sure whether the medicine has this smell but suspect that it could have expired, always consult your doctor before taking it.

Storage

Butalbital, aspirin, and codeine tablets or capsules should be stored in a cool, dry environment, away from heat, moisture and direct light. They should be kept from freezing. They should be store in a closed container up and away from the ground so that they are not within easy reach of children or pets. It’s also important to avoid sharing this medicine with others because some of the ingredients may be harmful if taken in conjunction with other drugs or by people with other pre-existing conditions. The drugs should only be taken by the person they have been prescribed to.

Do not hold onto expired medicine or unused medicine if you no longer need to take it. Consult your healthcare provider for advice on how to dispose of the medicine safely. Do not flush the drugs down the toilet, pour them in the drain or toss them in the trash without first speaking to your healthcare provider, as they could be harmful to the environment.

Summary

Butalbital, aspirin, and codeine is a combination painkilling drug used to treat headache and migraine. Butalbital relaxes muscles throughout the body, while codeine is a narcotic analgesic which relieves pain, and aspirin reduces substances in the body responsible for pain and inflammation. Caffeine is also included in the drug combination to heighten the effects of aspirin.

Butalbital and codeine are both habit-inducing drugs which means that they cause physical and mental dependency when used for long periods of time. For this reason, the drugs should only be administered in the lowest possible doses and they should only be taken as and when headache or migraine strikes, rather than on an ongoing basis. People with a history of drug abuse or dependency may be at an increased risk of developing a dependency to butalbital, aspirin, and codeine.

Codeine and butalbital are both central nervous system (CNS) depressants. They should be used with great caution with other CNS depressants, as high levels of these types of drugs can slow breathing and cause life-threatening complications. Tranquilizers, muscle relaxers, anti-seizure medications and anti-anxiety medications are all examples of CNS depressants. Anesthesia is also a CNS depressant, so it’s vital that you tell your doctor or dentist that you’re taking butalbital, aspirin, and codeine before you undergo surgery, no matter how minor. It may be necessary to stop taking the drug for a short period before the surgery. It’s also important to note that alcohol is a CNS depressant, and that when alcohol is consumed with butalbital, aspirin, and codeine it can cause very dangerous effects. For this reason, alcohol should be avoided completely while taking this medicine.

Aspirin isn’t a habit inducing drug or a CNS depressant, but it is incredibly dangerous when taken in high doses. For this reason, it’s important that you don’t consume any other medicines which contain aspirin without checking with your doctor that it’s safe to do so. Aspirin is often found in over-the-counter pain medicines and cold, flu and allergy medicines. Check the ingredients of medications before you take them, and look out for ASA which is what aspirin is often referred to as.

The most serious side effects to look out for when taking butalbital, aspirin, and codeine are those related to respiratory depression. If you have trouble breathing, tightness in the chest, wheezing, coughing or chest pain, seek urgent medical care as soon as possible. You should also look out for signs of allergic reaction to the drug; swelling of the face, mouth and throat, hives and skin rashes and sudden, severe dizziness are all signs of allergy and signal that urgent medical care is needed.

The most common side effect associated with butalbital, aspirin, and codeine is drowsiness, and this is down to the depressant effect on the nervous system. It’s normal to feel a little dizzy or sleepy, but if it becomes very severe seek urgent medical care. You should also take care to avoid driving or operating machinery if this medicine makes you dizzy or drowsy. Sometimes the drowsiness dissipates once your body adjusts to the medication.

Butalbital, aspirin, and codeine should be taken with food or water whenever a headache or migraine strikes. The sooner the medicine is taken after symptoms of headache begin, the more effective it will be in reducing or preventing pain. It is not, however, a long-term preventative drug and doesn’t have to be taken at regular intervals unless a migraine occurs. Doses should be no less than four hours apart, and no more than 6 capsules or tablets should be taken in one day. The typical recommended dose is one to two capsules.

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Last Reviewed:
December 22, 2017
Last Updated:
December 22, 2017
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